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Name
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First
Last
Email
*
Phone Number
*
How do you prefer to be contacted?
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Phone
Email
Age(s) of the client
*
What insurance do you have?
*
Aetna
BCBS/Florida Blue
Cigna
ComPsych
Humana
Lyra
Medicare
United Healthcare
Self pay
Tricare
Other
What type of appointment are you seeking?
*
Medication Management
Therapy
Both
Would you prefer virtual or in-person sessions?
*
In-person
Virtual
First Available
If in-person, which location do you prefer?
*
Does Not Apply
Riverview
Temple Terrace
If seeking therapy, what kind of therapy are you looking for?
Individual
Family
Couples
Which Therapist Would You Like to Work With?
Anyone is great!
Justine Alemany
Ashley Aplin
Meredith Chrystie
Alisa Davis
Glo De Jesus
Sarah Doan
Rachel Elzey
Jennie Gintoli
Kendal Hansen
Brittany Joseph
Francia Pierre
Sara Sharp
Which Nurse Practitioner Would You Like to Work With?
Anyone is great!
Patricia Hoyt
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