Name *

First Name

Last Name

Phone *

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Contact by? *

Call

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Please check all that apply *

I am interested in:

Individual Therapy

Couples Counseling

Ketamine Assisted Therapy

Medication Management

Which insurance do you have: *

NOT ACCEPTED - Anthem / Blue Cross Blue Shield - Self Pay rates apply

Self Pay

Aetna

Cigna

Connecticare

Medicaid / Husky

Medicare

Magellan / Yale Health

United Behavioral Health

United Healthcare

Plus supplemental / secondary insurance

Not listed - Ask if accepted