Which services are you seeking? *

Individual Therapy

Couples / Relationship Therapy

Individual Consultation

Professional Relationships Consultation

Other (please describe below)

I offer video and in-person sessions. How do you hope to meet? *

I am interested to meet via video

I am interested to meet in person

I do not have a preference or would be comfortable with either format

Name *

First Name

Last Name

Phone Number *

(###)

###

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Location *

Please note your expected location for sessions

North Carolina

Pennsylvania

Maryland

Another State or Country

Insurance Coverage *

I am in-network with most plans of Blue Cross and Blue Shield (BCBS) and Aetna. Must be located in North Carolina at the time of sessions for in-network billing.

I have BCBS Health insurance and wish to use it

I have Aetna Health Insurance and wish to use it

I would pay directly for sessions

My availability is currently limited to weekdays and I do not currently have openings before 9:30 or after 4:30. Could that work for you? *

Yes, I have some availability to meet during those hours Monday - Friday.

Yes, but I have very limited weekday availability (if so, please note availability below under Additional Information)

Are you seeking therapy related to any past, current, or expected future civil or criminal court case? *

No

Yes - please briefly describe under Additional Information