Name *

First Name

Last Name

Phone Type *

Home | Mobile | Work

Home

Mobile

Work

Preferred Method Of Contact *

How would you like us to contact you?

Phone, Voicemail, Email, Text = OK (outgoing text appointment reminders)

Phone, Voicemail, Email = OK

Phone Call = OK (No voicemail)

Phone Call & Voicemail = OK

Email Only

Consultation Option *

Would you like to have a free (30min.) consultation before you start therapy?

Yes

No

Availability *

Open Office Hours: Mondays (4pm-8pm) and Tuesday - Thursday (1pm - 8pm). Frist session begins at 11am and last session begins at 7pm.

Afternoon Only (1pm -3pm)

Mid-Afternoon (3pm -5pm)

Evenings Only (5pm -7pm)

Very Flexible Schedule (Monday - Thursday, 1 pm - 7pm)

Days You Can Meet? *

What days work best for you to meet? You can choose more than one.

Mondays

Tuesdays

Wednesdays

Thursdays

Desired Intake Date

Typical turnaround time from insurance verification to first scheduled intake appointment is 3-5 business days.

MM

DD

YYYY

Do you have insurance that covers tele-health? *

MLC does NOT accept the following: Medicare, Medicaid, HRA, PMAP, sliding scales, or payment plans.

Yes

No

I don't know

Insurance Coverage *

Select the insurance type below. If you don't see your insurance type listed it means that MLC doesn't accept that insurance at this time.

Aetna

Blue Cross Blue Shield (BCBS)

No Insurance / Self-Pay

Military Service Member

Veterans and Reserve (If choosing Self-Pay, we have a reduced rate for you).

Yes

Date of Birth *

We will use this for insurance verification.

MM

DD

YYYY

Name *

Please only complete this form if you are the one seeking services.

First Name

Last Name

Phone *

(numbers only - no special characters) If MLC leaves a voicemail, we will not mention our company name, yet we will let you know that you're being called about the waiting list. Our caller ID will read "MLC Office".

(###)

###

####

Phone Type *

Home | Mobile | Work

Home

Mobile

Work

Preferred Method of Contact *

How would you like us to contact you with an update? SELECT ONE

Phone, Voicemail, Email, Text = OK (outgoing text appointment reminders)

Phone, Voicemail, Email = OK

Phone Call = OK (No voicemail)

Phone Call & Voicemail = OK

Email Only

Consultation Option

Would you like to have a free (30 min.) consultation before you start therapy?

Yes

No

Do you have insurance that covers tele-health? *

MLC does NOT Accept: HRA, EAP, or Medicare plans. No cash, checks, sliding scale, or payment plans. Self-Pay option is available ($115 per session or $100 per military/veterans).

Yes

No

I don't know

Insurance Coverage *

Select the insurance type below. If you don't see your insurance type listed it means that MLC doesn't accept that insurance at this time.

Aetna

Blue Cross Blue Shield (BCBS)

No Insurance / Self-Pay

Military? *

Yes

No

Availability *

Open Office Hours: Mondays (4pm-8pm), and Tuesday - Thursday (1 pm - 8 pm). First session begins at 11am and last session begins at 7pm.

Early Morning / Afternoon (11 am - 1pm)

Afternoon Only (1pm - 3pm)

Mid-Afternoons Only (3pm - 5pm)

Evenings Only (5pm -7pm)

Very Flexible Schedule (Tues. - Thurs., 11 am - 7pm)

Days You Can Meet? *

What days work best for you to meet? You can choose more than one.

Mondays

Tuesdays

Wednesdays

Thursdays

Urgency

Let us know where you are at in the process of finding mental health services.

I'm a referral

Looking to start as soon as possible

Interested in a Free Consultation

Starting my search for a therapist / shopping around

General Inquiry / Not Urgent

Preferred Start Date

MM

DD

YYYY