Name *

First Name

Last Name

I'm interested in: *

Individual Therapy

Relationship Therapy

DBT Group

Other

I am a resident of North Carolina *

Yes

No

Moving there soon

I am a resident of New York state. *

Yes

No

Moving there soon

I am a resident of Vermont *

Yes

No

Moving there soon

I am at least 24 years of age *

Yes

No

My insurance plan is through:

Aetna

Cigna

United or Optum

BCBS

Other

No insurance

By submitting this form via this web portal, I acknowledge and accept the risks of communicating health information via this unencrypted email and electronic message and wish to continue despite those risks. *

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