Full Legal Name *

First Name

Last Name

Phone *

(###)

###

####

Are you a New or Returning Clint? *

New Client

Returning Client

What services are you looking for? (Check all that apply) *

Individual Therapy

Neurofeedback

Ketamine-Assisted Therapy

Couples' Therapy

Individual Therapy for a minor - under 18

Family Therapy

We accept the following health insurances. Please check all that apply, if you have more than one insurance coverage. Any insurances not listed are out of network. *

Blue Cross Blue Shield (BCBS)

Select Health - Med, Value, or Care

EMI

University of Utah - Healthy Preferred or Healthy Premier

BCBS/HMHI-BHN (affiliated as a University of Utah employee or family member)

DMBA

I don't have insurance/I will be paying out of pocket

Other

If you are using insurance, do you have a deductible to meet? *

Yes

No

Unsure

N/A

Which location would you prefer? (Select all that apply) *

Salt Lake

Cottonwood Heights

Provo

Virtual Only

Hybrid (In-Person and Virtual)

Therapist preference? *

Male

Female

Other Preferences

First Available