Preferred Name *

First Name

Last Name

Phone *

(###)

###

####

Is the potential client 18 years of age or older? *

If you are younger than 18, your parent must consent before scheduling can occur.

Yes

No

Interested In... *

Please check all that apply.

Individual (Adult)

Individual (Teen 13-17)

Couples (Insurance not accepted)

Group (Insurance not accepted)

EMDR Intensive (Insurance not accepted)

Ketamine Assisted Psychotherapy (Insurance for individual Intake and Integration only)

How would you prefer services to be delivered? *

In-Office

Online

If online, please indicte which state the potential client will be located? *

Clients must be located in the same state that the Clinician is licensed.

DC

Maryland

Virginia

N/A

Likely to Use.. *

Please indicate which option you will likely use in order to cover services.

Aetna

CareFirst / Blue Cross (Includes all plans)

Cigna (Includes all plans)

United Health Care

Out of Network Benefits (Insurance not listed)

Self-Pay

Other (e.g. Loveland Voucher)

Referred by.. *

Please indicate who you were referred by.

Self

Friend

University of Maryland

Therapy for Black Girls

Another Counselor / Therapist

Primary Care Physician

Hospital

PHP

School

Social Media

Other