Name *

First Name

Last Name

Phone *

(###)

###

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Preferred Contact Method *

Phone

Email

Age *

(note: we currently do not work with children under 5 in our private practice):

I am seeking services for child between the ages of 5 and 7

I am seeking services for a child between the ages of 8 and 12

I am seeking services for a minor between the ages of 13 and 17

I am seeking services for an adult

I am an adult seeking services for myself

What issues would you like to address in therapy? *

Anxiety

Depression

Bipolar Disorder

Relationship Issues

Peer Issues

ADHD

Academic Issues/ Behavioral Issues in School

Trauma

Grief/Loss

Low Self Esteem

Difficulty with Life Transitions

Family Issues

Other

Is there a specific therapist you'd like to work with? *

Nate Magneson (telehealth)

Marence Edu (telehealth)

George Williams (telehealth)

Maggie Blackburn (telehealth)

Alexus Ford (telehealth)

Tracy Gordon (telehealth)

Insurances Accepted *

CareFirst Insurance

Medicaid Insurance

Self Pay

Out of Network Benefits

Sliding Fee Scale

What day of the week works best for you? *

Select all that apply

Monday

Tuesday

Wednesday

Thursday

Friday

Is there a certain time of day that you require for an appointment? *

Morning

Afternoon

Evening

Flexible

How did you hear about us? *

Instagram

LinkedIn

Google

Referral