Phone Consultation Request Fill out the form below and the clinician you request a call with will contact you shortly. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.First Name *Last Name *Email *Phone Number * check plan which Do you plan to use insurance? *YesNoIf you plan to use insurance, which plan to you have? *No insurance. I will use private pay.AetnaBlue Cross Blue ShieldCigna/EvernorthUHC/OptumOtherIf you selected 'Other' above, please let us know which plan you have.Which clinician would you like to speak with? Please check out the 'Our Team' page for all of our clinicians' profiles. *No preferenceChey DavisDiana VarugheseMarianne Redmond LopezNedra SmithSidney BohanenKayla GiltzStacey KaminskiPlease specify an alternate clinician. *No preferenceChey DavisDiana VarugheseMarianne Redmond LopezNedra SmithSidney BohanenKayla GiltzStacey KaminskiPlease specify one more alternate clinician. *No preferenceChey DavisDiana VarugheseMarianne Redmond LopezNedra SmithSidney BohanenKayla GiltzStacey KaminskiFirst Choice *DateTimePlease specify 3 dates/times that work best for contacting you. You will receive an email from your therapist to confirm the date/time of the call prior.Second Choice *DateTimePlease specify 3 dates/times that work best for contacting you. You will receive an email from your therapist to confirm the date/time of the call prior.Third Choice *DateTimePlease specify 3 dates/times that work best for contacting you. You will receive an email from your therapist to confirm the date/time of the call prior.Message/CommentsPlease share anything you feel is helpful here. A response here is not required.Prove You Are Human: * = Send Message
