Book an Appointment

First Name:

Last Name:

Email Address:

Phone Number:

Date of Birth:

How did you hear about us? How did you hear about us? Friend/Family Doctor/Professional My Insurance Company Psychology Today Instagram Facebook Google Search Other

Please specify if referral source selected was "other"

Select your preferred payment/insurance Select your preferred payment/insuranceAetnaBlueCross BlueShieldCarelonCignaLyraPrivate PayOther

Please specify if your chosen payment was "other"

What are you seeking therapy for? What are you seeking therapy for? Anxiety Depression Trauma/PTSD Couples Therapy Relationship Issues Women's health including postpartum Other

Please specify if your therapy selection was "other"

Preferred Therapist: Preferred Therapist:Coralis Solomon, PhD, LMHCLucia Martin, LMHCKristine King, LCSWAssel Saparova, MA, LMFT MTNicole King, MSNo preference

Legal Name (If different from preferred name, required for insurance purposes)

Preferred Pronouns

What days do you prefer for appointments? What days do you prefer for appointments? Monday Tuesday Wednesday Thursday Friday

What are your preferred timeframes for your appointments? What are your preferred timeframes for your appointments? Mornings (7-9am) Late Mornings (9-11am) Lunch Time (11-2pm) Afternoon (2-5pm) Evening (5-8pm) No Preference

Is there anything else you would like to share? Or specific scheduling requests?