Name *

First Name

Last Name

Phone *

(###)

###

####

Are you comfortable with us leaving a message identifying ourselves as The Therapy Group at the phone number you provided? *

Yes

No

If in person isn't available, are you comfortable with virtual?

Yes

No

Would you be comfortable staying virtual? *

(Never moving to in-person therapy)

Yes. I am comfortable staying virtual.

No. I would like to eventually be in person.

N/A

I would prefer if my therapist is *

No preference

Female

Male

LGBTQIA+

BIPOC

Daily Availability (check all that apply) *

Monday

Tuesday

Wednesday

Thursday

Friday

Time Availability (check all that apply) *

Morning (8am-10am)

Late Morning (10am-12pm)

Mid-Day (12pm-2pm)

Afternoon (2pm-4pm)

Late Afternoon (4pm-6pm)

Evening (6pm - 8pm)

Insurance disclaimer *

By clicking this, I understand that The Therapy Group is not in network with any insurance providers. If you wish to get reimbursed, your therapist will work with you to help you submit out of network super bills. The Therapy Group also accepts HSA or FSA cards in addition to all other forms of payment