New Client Appointment Request Form.
First Name
Email
Are you interested in
Coaching with Mariah - This service is NOT covered by health insurance.
Therapy with Mariah - This service is covered by the most health insurance.
Therapy with Scott - This service is covered by the most health insurance.
Therapy with Susan - This service is covered by the most health insurance.
Currently Telehealth therapy via video only, are you open to this method of therapy?
Yes
No
What is your health insurance?
If no health insurance, are you looking to pay out of pocket?
Yes
No
I have insurance
Who is this service for?
Adult
Teen - 16+
What is this appointment for?
Intake for therapy
Intake for coaching
What are you wanting to address during this appointment?
Phone Number
Submit