Name * First Name Last Name Email * Phone Number * I'm interested in help with... * Select all that apply Depression Anxiety Bipolar Disorder Grief ADHD OCD Insomnia Panic attacks PTSD Postpartum mental health Women's mental health Other If you selected other, please list what you're looking for Are you currently taking medication for your mental health? * Yes No If you answered yes to the above, please list all current medications. What insurance will you be using or will you be private pay? * Private Pay Cigna Aetna United Healthcare Oscar Health Oxford How did you hear about me? * Thank you! I look forward to getting in touch.