Name *

Name of the person completing this form

First Name

Last Name

Date of Birth *

For the person who will be attending therapy

MM

DD

YYYY

Are you hoping to utilize insurance or pay privately? *

At this time, I only accept insurance through TalkSpace and Headway. If you are interested in using your insurance, additional information will be provided to you. Please note I do not accept Medicare or Medicaid.

Insurance

Private Pay

Unsure (that's okay!)

Phone

(###)

###

####

How Can I Get Back To You? *

Select all that apply

E-Mail

Phone (you are authorizing me to leave a message)