Client Name
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First Name
Last Name
Client Date of Birth
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MM
DD
YYYY
Client Email
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Client Phone
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(###)
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Client Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Insurance Member ID:
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Primary Insurance holders name
Leave blank if non-applicable
First Name
Last Name
Primary Insurance holders Date of Birth
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MM
DD
YYYY
Primary Insurance holders Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
If Applicable, Which provider are you interested in working with?
Dr. Kevin Stewart, PsyD, LADC-I, CADAC-II, CCTP (Accepting new patients) Individuals, Couples, Adults, Elders, Groups
Rachel Greenberg, MS (Accepting new patients) Individuals, Adults, Elders, Preteens, Teens
Joan Juhnke, LMHC (Accepting new patients) Individuals, Adults, Elders
Annie Huddle, LMHC (Accepting new patients) Individuals, Adults, Elders, Children (ranging about 6-10yo)
Michelle Crellin, LICSW (Not accepting new patients) Individuals, Families, Children, Adolescents, Preteens, Teens, Toddlers
Ruthie Fox, LICSW (Not accepting new patients) Individuals, Couples, Families, Children, Adolescents
Ella Huzdovich, LMHC (Not accepting new patients) Individuals, Groups, Adults
Robert Titus, LMHC (Not accepting new patients) Individuals, Couples, Family, Groups
*I would like a professional recommendation! *All referrals are reviewed by a fully Licensed Counselor and recommended therapists are based off of presenting concerns and provider specialty
In-person or virtual preference
Message
Presenting concerns, what brings you to therapy etc.
