* If you are using your health insurance, you may need to contact your insurance company in order to find out how they cover behavioral health same as your medical coverage and is not usually listed on your insurance card.
- Name of Insurance company?
- Deductible Information? How much of your deductible have you met?
- Will you be using an EAP? An authorization number will be required.
- What would you like to accomplish in counseling?
- Do you prefer telephone or video conferencing for appointments?
- Days and times you are available for appointments?
We are committed to your privacy. Do not include confidential or private information regarding your health condition in this form or any other form found on this website. This form is for general questions or messages to the practitioner.