First Name *

Last Name *

Email *

Phone

Date of birth *

Address *

City *

State *

Postal code *

Clinician you’re interested in working with? *

Any available clinician
Graduate student intern
Rebeka
Kelly
Elena
Drew
Maggie
Gabby
Sarah
Kristin
Christina
Leslie
Abby Behar
James
Camille
Nik
Abimael
Heather
Hayden
Sophie
Briellen
Kathryn
Charlie
Madison
Maegan
Anne
Jil
Stef
Abby Birk
Toni
No elements found. Consider changing the search query.
List is empty.

How Would You Like To Receive Services *

In-Person Only

Telehealth Only

Open to Both

Do you plan to use insurance to cover services? *

Yes
No
No elements found. Consider changing the search query.
List is empty.

If you do plan to use insurance, please upload a copy of the front and back of your insurance card (if you don't have your insurance card on you right now, please at minimum tell us your insurance carrier). If you are not planning to use insurance, you can skip this section.

Insurance carrier name

Insurance ID number

Upload insurance card (Front)

Upload insurance card (Back)

Brief description of what you're seeking support around and any questions you have *

Days of the week you are available for scheduling *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Times of day you are available for scheduling *

Mornings (8-12)
Mid-day (12-3)
Afternoons (3-5)
Evenings (5-9)
No elements found. Consider changing the search query.
List is empty.

Any other notes on your schedule availability? *

Have you had a recent suicide attempt or current suicidal thoughts? *

Yes
No
No elements found. Consider changing the search query.
List is empty.

Have you had any recent hospitalizations, PHP or IOP treatment for mental health? *

Yes
No
No elements found. Consider changing the search query.
List is empty.

If yes to either of the above two, please share a bit more detail

How did you hear about us? *

Google search
Google ad
Psychology today
Other online directory
Referral from another providers
Referral from friend/family member
Social media (instagram, facebook)
Other
No elements found. Consider changing the search query.
List is empty.

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

TheraSaaS