Name *

First Name

Last Name

Phone *

(###)

###

####

What type of therapy are you interested in? *

Virtual Therapy

Walk and Talk Therapy

In which state will you be physically located at the time of your therapy sessions? *

Pennsylvania

Massachusetts

How do you intend to pay for therapy? *

I intend to pay out of pocket. Full fee due at time of service; rates as of 1/01/25 are $200 for a 75+ minute intake session and $175 for a 50+ minute ongoing therapy session.

I intend to use my out-of-network health insurance benefits (if eligible). I will pay the full fee and submit a receipt to my insurance company for partial reimbursement.

I intend to use my in-network health insurance benefits.

Non-Eligible Insurance Plans

I understand that Medicare and Medicaid insurance plans are not accepted.

I understand.

I'm not sure whether I have a Medicaid or Medicare plan.