Name of Potential New Client *

First Name

Last Name

Date of Birth of Potential Client *

MM

DD

YYYY

Phone

(###)

###

####

Preferred Counseling Setting *

In Person, Haymarket Office

Virtual

If In Person unavailable, Willing to meet Virtually

Method of Payment Preferred *

In- Network Insurance/Direct Pay

Anthem/BCBS

Anthem Healthkeepers Plus

Cigna

Carefirst

Aetna

Out of Network/Direct Pay