NEW CLIENTAppointment Request We’re so glad you’re here. Thank you for completing this form. Please expect a response within 24 hours. We are only in network with BCBS PPO plans. Do you plan on using this insurance for your visit? * Yes, I do plan to use my BCBS PPO insurance No, I plan to pay the out of pocket session fee. Out of pocket session fees are $175 for the initial session and $150 for each additional session thereafter. Name * First Name Last Name Email * Can we email you? * Yes No Can we add your email to our newsletter list? * Yes No Phone * (###) ### #### Can we call you? * Yes No Can we text you? * Yes No What city & state do you live in? * City/State Are you seeking services for * Yourself Your Spouse/Partner Yourself + Spouse/Partner Your child Your family Other What brings you to therapy? * How did you hear about Tend Therapy? Is there a therapist you prefer to see? * Angela Michalak, MA, LCPC Kari Wittman Lata, MS, LCPC, LMFT Pam Caine, MSW Sarah Greene, MS, LCPC Deb Grizzell, MSW, LCSW Katie Scheer Dawson, MA, LCPC Brooklyn Miller, Clinical Intern (Brooklyn cannot submit to insurance however her sessions are a reduced rate of $25/hour) Carrie Thayer, MA, LMFT No preference What is your availability? Select all that apply. Mornings (9a-12p) Afternoons (12p-5p) Evenings (5p-9p) Weekdays (M-F) Weekends (Sa-Su) Do you have a preference for in-person or teletherapy? * I prefer in-person I prefer teletherapy I have no preference Thank you for providing Tend with this information. Once we receive your submission, we will email or call you as soon as possible to further the process.
