Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Phone *

(###)

###

####

Payment Preference *

Self Pay

Use Insurance (not available for couples counseling)

Type of Insurance

Aetna

Blue Cross Blue Shield (MA only)

Cigna

United Healthcare

Other

Session Preference *

In Person

Telehealth (not available for couples counseling)

Addiction & Recovery Statement *

We do not work with clients dealing with addiction or recent recovery. If recovery is part of the picture, we require 5+ years in recovery in order to work with a client as we do not have a clinician trained in addiction or recovery counseling.

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