First Name *

Last Name *

Email *

Phone *

Preferred method for contact when scheduling

Phone Call

Text

What format of services do you prefer? *

Virtual (telehealth)

In-Person

Either one is good (virtual or in-person)

Are you a Texas resident? *

Yes

I'm not sure

Who are you contacting us about? *

Myself

A Minor child

An Adult Dependent

Format of therapy you are seeking: Choose all that apply

Do you know which counselor you'd like to see?

* If the counselor you choose is not accepting new clients, we will help you get connected with another provider. You can choose more than one.

Topics you want to explore in counseling:

Select all that apply

Do you have specific scheduling needs?

I'm flexible

I have specific scheduling needs

Payment Preferences *

I plan to pay privately

I plan to use my out-of-network insurance benefits

I plan to use my insurance

I need help with payment options including reduced fee services and/or how to use my health savings account.

Whole Foods EHN: All of our providers are in-network with Whole Foods EHN, but you may want to contact them to confirm your benefits or have us do an electronic benefits check for you, see below. All plans with EHN have a deductible that resets at the beginning of the year. While your deductible is being met, you are responsible for the cost of services out of pocket. Once your deductible is met, your responsibility is 30% of the fees. We do accept the Health Savings Account card from Whole Foods, which you can use to pay for your portion of the services.

Can we check your benefits? *

I won't be using my insurance benefits

I give permission for you to check my benefits

Using insurance? Please upload images of the front AND back of your insurance card

** If you DO NOT upload both images, we can't quote benefits.

Please tell us a little about your goals and/or what you'd like to work on in therapy or nutrition counseling at this time? *

If you'd prefer not to share right now, please just type N/A

We look forward to helping you find the support you deserve!

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