Request An Appointment Please enable JavaScript in your browser to complete this form.Client Name *FirstLastIs client under 18? *yesnoYour Relationship To Client *Parent/GuardianSelfParent/ Guardian Name *FirstLastEmail * Phone *Location *IndianapolisKissimmeeLeominsterServices Needed *Individual TherapyGroup TherapyMedication ManagementPsychiatric EvaluationSession Type *In PersonIn Person – GroupTelehealthBoth – HybridPayment Method *Self PayInsuranceInsurance ProviderPolicy Number Policy Holder's NameFirstLastWhy Are You Seeking Therapy? *I Am Anxious/OverwhelmedI am DepressedStruggling with relationshipsI Am GrievingBattling AddictionI Want To Improve Self ConfidenceI Experienced A TraumaRecommended (Family, Friends, Doctor)I Have A Mental DisorderOtherSubmit
