Name *

Age of Person Receiving Services *

Phone *

Email *

Session Preference *

Telecare Sessions

In-Person Sessions

Both Telecare and In-Person

Preferred Contact Method *

Email

Phone

Text

Are you looking for a specific type of therapy?

I am open to any therapy that works!

Exposure and Response Prevention (ERP)

Inference-Based Cognitive Behavioral Therapy (I-CBT)

Acceptance and Commitment Therapy (ACT)

Mindfulness-based therapy

Other

Preferred Time for Appointments (Select all that work) *

Morning (8am-11am)

Mid-Day (11am-2pm)

Afternoon (2pm-5pm)

Evening (5pm-7pm)

Insurance/Payment Preference *

I will be private pay/cash pay

I would like to use Aetna Benefits (AZ Clients Only)

I would like to use BCBS Benefits (AZ Clients Only)

I would like to use UHC Benefits (AZ Clients Only)

I would consider private pay for a perfect fit

Additional information (optional)

Name of preferred therapist, other information