First Name *

Last 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

Briefly Describe Your Goals for Therapy

Is there anything you are looking for in a therapist? (Examples: Female, age, laid back, professional, POC, tattoos/edgy, etc...)

Preferred Time for Appointments *

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