Tell us about you! *

First Name

Last Name

Phone

(###)

###

####

Location *

Commerce City

Colorado Springs

Loveland

In Person or Telehealth Preference *

In Person Only

Telehealth Only

Flexible

Types of Services *

Please check all that apply and share more info in the message box below

Play Therapy

Child or Adolescent Therapy

Adult Indiviudal Therapy

Couples Therapy

Family Therapy

Group Therapy

EMDR thearpy

What are your preferred days and times for therapy sessions? Please provide your general availability to help us schedule appointments that best suit your needs. *

Please select all that apply for weekdays:

8-10am

10am-12pm

12-2pm

2-3pm

3-5pm (NOTE: These slots are considered prime-time and tend to fill up quickly)

Other (please explain below)

Payor Source *

(Please check all that apply)

BCBS (We do not accept BCBS HMO plans)

United Health Care

Cigna/Evernorth

Aetna

Medicaid (Please provide the client's Date of Birth below to allow us to verify eligibility for benefits).

Private Pay

Other