SCHEDULE A CONSULTATION YOUR PATH TO PEACE AND WELL-BEING APPOINTMENT FORMFill out the form below, and we will get back to you in a few hours. Emails received evenings/weekends are returned the next business day.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. seeking primary Name Name *FirstLastPreferred Name (if different than Legal name) Preferred NamePreferred Contact Method: *PhoneEmailPhone *Email *What types of services are you looking for:Therapy for MyselfCouples CounselingTherapy for Someone ElseDate of Birth *MM/DD/YYWhat Is The Primary Insurance Programs(We do not accept Secondary Insurance or EAP programs) *AetnaAnthem/Blue Cross Blue ShieldCignaHealth PartnersOptumMedicaUnited HealthcareUMROtherI Prefer to not use Insurance (most confidential option)Please briefly describe the primary reason(s) for seeking therapy or support at this timeSubmit Email:[email protected] Call Us:651.321.8845 Fax:651.280.4480
