Please complete the appointment request form. We will contact you. Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone * (###) ### #### What services are you requesting * Individual Counseling Family Counseling Couples Counseling How will services be covered? * Care First (BCBS) Aetna Cigna Employee Assistance Program (EAP) Self-Pay Other Please enter you insurance Member ID Best time to call you at the phone number provided? * Anytime Mornings (10am - Noon) Afternoons (2pm - 4pm) Evenings (6pm - 8pm) How soon are you looking to schedule your first appointment? * ASAP This week Next week Next month Message Feel free to ask anything you want here. You may request an appointment, a consultation, or ask a quick question. We promise to respond to all inquiries within 24-48 hours. Thank you for reaching out to us. Your wellness is important, and I would be glad to speak with you about our services. But before moving forward I'd like to provide you with some additional information so you can make an informed decision. All appointments are virtual. Our appointment scheduling availability right now is weekdays only (excluding Friday and holidays) between 9am and 7pm. We are currently only accepting individual clients ages 14 and older. We are not accepting new clients for family and/or couples therapy. We are only accepting Care First, BCBS and Aetna insurances, but would be happy to look into your out of network benefits if you have them, or self pay. If this information works for you, I will happily schedule a consultation call with you. If this information does not work for you, I’d be happy to send you alternative resources to continue your search. Best Regards, Cleonia Terry, MSW, LCSW-C Family Focus Therapy !
