Name *

First Name

Last Name

Phone *

(###)

###

####

Services Requested *

Check all that apply

Adult Individual

Adolescents

Couples or Family Therapy

Consultation

Other

Would you consider to pay a reduced out-of-pocket for pre-licensed clinicians? *

The reduced self-pay option ($65/ individual sessions; $75 couples and family sessions) may be ideal if: ✓ You value privacy (no treatment records submitted to insurers) ✓ You don't have insurance but want quality care ✓ We don't accept your insurance ✓ You're seeking couples/family therapy ✓ You prefer straightforward pricing without copay surprises **Residents are pre-licensed master-level clinicians that provide skilled therapy under direct supervision, with the same confidentiality protections as licensed clinicians. ***Full fee self-pay rates with licensed clinicians qualify for Super Bills.

Yes, I’d like the reduced self-pay rate ($65/$75 per session with a pre-licensed clinician)

No, I would like to use my insurance if possible

Maybe, I would like to learn more

Other

Do you have Insurance? *

Check all that apply

Yes

No

Other