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First Name
*
Last Name
Email Address
*
Phone Number
Preferences for service
Individual
Couples
Family
Group therapy
Psychological Assessment
Desired Clinician
Michael Bricker, PhD
Lilia Berkovich, PsyD
Amedee St. Pierre, PsyD
Elliott DeVore, PhD
No preference
If your preferred clinician is not taking on new clients at this time, are you open to working with a different clinician?
Yes
No
What insurance do you have?
Blue Cross Blue Shield PPO
Out of Pocket
Other
If "Other," please enter it in this field
What brings you to therapy?
What days and times are you available for sessions?
Session Preference:
Virtual
In Person
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