Full 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
Optional: Briefly Describe Your Goals for Therapy
Optional: Is there anything you are looking for in a therapist? (Examples: Female, age, laid back, professional, POC, tattoos/edgy, etc...)
Type of Therapy
*
I'm open to anything that works!
Cognitive Behavioral Therapy (CBT)
Dialectical Behavioral Therapy (DBT)
Eye Movement Desensitization and Reprocessing (EMDR)
EMDR Intensive
Exposure and Response Prevention (ERP)
Brainspotting
Trauma Therapy
ADHD counseling
Internal Family Systems (IFS)
Other
Preferred Day for Appointments
*
Monday
Tuesday
Wednesday
Thursday
Friday
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
How Did You Find Us
Google Search
Referral from Doctor/Therapist
Instagram/Facebook
Psychology Today
Other
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