Name *

First Name

Last Name

Preferred language:

English

Spanish

Phone *

(###)

###

####

Is it okay for me to leave a voicemail, if I cannot reach you via phone? *

Yes, that is okay.

No, please do not.

What services are you interested in? *

Talk Therapy (for adult individuals only)

Immigration Mental Health Evaluation

If interested in talk therapy, which do you prefer:

Virtual (offered for those living anywhere in Texas)

In Person (offered only in Amarillo, TX)

Form of payment: Currently accepting debit cards, credit cards, or FSA/HSA cards. Also accepting most insurances. Full payment is expected at the time of services and is processed electronically via a secure platform. *

Immigration Evaluation- Self Pay only

Self- Pay: Talk Therapy

Aetna Insurance

Blue Cross Blue Shield of Texas Insurance

Cigna Insurance

Oscar Health Insurance

United Healthcare

EAP benefits

Oxford Insurance

Unsure

I am only licensed in Texas. Do you reside in Texas? *

Yes!

No, but I will in the near future.

You must be 18 years or older to submit request: *

Please note: Counseling services are not offered to couples or families. Only individual counseling services available at this time.

I am 18 years old or older

I understand that my information will be securely saved and I will be contacted as soon as possible. *

I understand