Full Name *

Phone *

Email *

City *

State *

Whom are you seeking counseling for? *

Would you like first availability or to work with a specific therapist? *

When are you regularly available for therapy? *

What's the best way to contact you? *

How do you want to pay for therapy? *

IMPORTANT!

We are only in-network with Aetna, Cigna, United Healthcare, Oscar Health, Oxford, and Premera Blue Cross of Washington for Employer and Individual plans.

We CANNOT accept any plans for Medicaid, Medicare, or Washington Apple Health.

Briefly describe the issue you would like to work on. *

How did you hear about us? *

Email Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to The Center for Mental and Sexual Health therapists and/or office staff communicating with me via email or text message.

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