Schedule Appointment Name:(Required) Email:(Required) Phone:(Required)Age: Child/Adolescent <18 Young Adult 18-24 Adult 25+ Preferred payment method: Blue Cross Blue Shield PPO Aetna PPO Cigna PPO United Healthcare PPO Lyra Health Out-of-Pocket In-person or virtual appointment? In-person Virtual Mixed - Virtual and In-person No preference Would you be open to considering virtual therapy sessions if an in-person appointment isn't available at your preferred time? Yes No I’m available to make an appointment on (check all that apply): Monday Tuesday Wednesday Thursday Friday Saturday Sunday Preferred appointment time: Morning Afternoon Evening Any Type of Service: Individual Therapy Couples Therapy Family Therapy Neuropsychological/Psychological Testing Professional Coaching How did you hear about us: Web Search Trusted Personal Contact Referral (doctor, psychiatrist, hospital, therapist, health center, etc) Other Specify: If known, reason for seeking therapy:Any additional comments of concerns:Section Break Δ
