Name *

First Name

Last Name

Location *

In what state do you reside? I am currently permitted to provide therapy to clients located in Pennsylvania and New Jersey.

Pennsylvania

New Jersey

Payment Method *

I am currently in network with Aetna, United Healthcare, Quest Behavioral Health, Oscar, and Oxford. My private pay rates are $150 for initial intake and $125 for individual sessions. Which method of payment do you plan to use, should we go forward with treatment?

Aetna

United Healthcare

Quest Behavioral Health

Oscar

Oxford

Private Pay

Have you engaged in therapy services before?

Yes

No

*

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