New Client Consultation Form

Insurances Accepted: Aetna, Ambetter, Anthem, Beacon Health Options/Carelon, BCBS, ComPsych, Cigna, Humana, Lifeworks, Magellan, Medicaid (Traditional, Superior Health Plan, Parkland, Molina, Aetna, UHC), Molina, Multiplan, Oscar, UHC, UMR *Certain providers are only in-network with specific insurance panels. **All providers are only offering Telehealth services.

I understand that I will receive services via telehealth.

All providers are strictly telehealth at this time.

Yes

Name

First Name

Last Name

Name

If parent or guardian, what is your child's first and last name? If this request is not for a minor, please type N/A.

First Name

Last Name

Phone

(###)

###

####

Which therapist are you interested in working with?

Imene Benslimane

Marco Gonzalez

Parker Forté

Raquelle Palmer

Yakira Miller

Will you be utilizing Insurance or Self-pay? If utilizing insurance please provide Insurance information.

What type of availability are you seeking?

Daytime appointments

Evening appointments

Weekend appointments

Issues/Goals for Therapy

Referral Source

Do you have any questions specific for your potential therapist?