Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Personal InformationFull Name *FirstLastEmail Address *Okay to email? *--- Select Choice ---YesNoPhone Number *Okay to Text/Okay to Leave Voicemail? *--- Select Choice ---Text and Voicemail OkayOnly TextOnly Leave a VoicemailNo to both.Which therapist would you like to meet with? *--- Select Choice ---No preferenceMarianne Redmond LopezTatiana AubreyTojyanna CaldwellKaren PoindexterBrandie SmithRaymond Bryant JrCharles RoseRiley MaxTiffany AlvordBeth MattesonRaymond Bryant JrSidney BohanenPlease select a second choice, in case your first choice is unavailable. *--- Select Choice ---No preferenceSidney BohanenMarianne Redmond LopezTatiana AubreyKayla GiltzTojyanna CaldwellKaren PoindexterRaymond Bryant JrBrandie SmithCharles RoseRiley MaxTiffany AlvordBeth MattesonHave you ever worked with a 3Cs therapist before (either through 3Cs or another practice)? *If no, skip the next two questions. *Yes, I have.No, I haven't.If 'Yes,' which therapist did you see?Item 2Sidney BohanenMarianne Redmond LopezTatiana AubreyKayla GiltzTojyanna CaldwellKaren PoindexterRaymond Bryant JrBrandie SmithCharles RoseRiley MaxTiffany AlvordBeth MattesonA therapist who is not on this list.If you worked with a therapist not on the list above, who did you see?Will you be using insurance? *--- Select Choice ---No, I am seeking private pay services.Yes - AetnaYes - Blue Cross Blue ShieldYes - Priority HealthYes - CignaYes - UHC/OptumYes - OtherIf 'Other,' please specify. a Have the Preferred Date *Preferred Time *Second Choice Date *Second Choice Time *We'd love to know why you're seeking therapy at this time so we can pair you with the best fit possible. If you feel comfortable sharing, please do!How did you hear about us? *--- Select Choice ---Please select a choice from the list below...GoogleFacebookLinkedInInstagramTwitter (X)TikTokBarkGood TherapyPsychology TodayBelonglyTherapist.comWebMD VitalsMental Health MatchTherapy DenFind Recovery ExpertsOne of your therapists or another team member.OtherIf you selected "One of your therapists or another team member" above, who can we thank? (Please list the person's name below.)Please prove that you are human by completing the equation below: * = CLICK HERE TO SUBMIT - See You Soon!
