Revised Appt Request Draft Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.This web form is secure and encrypted to protect your privacy Your information is kept strictly confidential Today's Date * you're apply) you Prospective patient's name *FirstLastPlease answer: *I'm filling this form out for myselfI'm filling this form out for a family memberYour name *FirstLastPatient's Age *Gender *What type of services are you seeking (check all that apply)? *Individual Adult CounselingIndividual Child CounselingCouples/Family CounselingGroup TherapyBiofeedback ServicesArt TherapyIn brief, please tell us what kind of help you're looking for *Which offices are you closest to? (select all that apply) *MaywoodLittle FallsSpringfieldWestfieldI am willing to do only Telehealth sessions if that is all that's availableI only want sessions by TelehealthClick here to see details of our office locations. What is your current insurance coverage? *Commercial insurance (Horizon BCBS, Aetna, Cigna, etc)MedicareI would like to be self-payReferred by Project Ezrah(Medicaid- we unfortunately do not accept)Click here to see what insurance we accept, as well as our fees. Your Phone *Best number to get in touch with youYour Email *For confirmation of receipt of this form and to get in touch with you Submit
