Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Phone *

(###)

###

####

What services are you interested in? *

Individual therapy

Trauma therapy / EMDR therapy

Coaching

I'm not sure yet

Daily availability (check all that apply) *

Monday

Tuesday

Wednesday

Thursday

Time availability (check all that apply) *

Morning (8am-10am)

Late Morning (10am-12pm)

Mid-Day (12pm-2pm)

Afternoon (2pm-4pm)

Late Afternoon (4pm-6pm)

Insurance disclaimer

By clicking submit, I understand that Neighborhood Therapy is an out-of-network provider and does not accept insurance directly. If I’d like to seek reimbursement, my therapist can provide me with a superbill to submit to my insurance. Neighborhood Therapy accepts HSA/FSA cards as well as all major forms of payment.