Full Name: *

First Name

Last Name

DOB:

Required if you want Nurtured Therapy, LLC to verify insurance eligibility and benefits.

MM

DD

YYYY

Phone: *

(###)

###

####

What is your preferred contact method?

Phone

Email

Is it okay to leave a voice message or reply by email? *

Yes, you can identify yourself and leave or send a message.

No, please do not leave or send a message.

I understand that Nurtured Therapy, LLC is primarily a fee-for-service organization. *

Yes, I am willing and able to privately pay for services.

Yes I understand, and I also have insurance I would like you to check to see if I am in your network.

No, I may need help problem solving financial barriers.

How do you plan to attend services? *

Telehealth

In-person

Both options sound nice

No preference