Name * First Name Last Name Email * Phone * (###) ### #### Location (State) * Birthdate * MM DD YYYY Services * Individual Psychotherapy Diagnostic Assessment ONLY Clinical Supervision Consult Payment Method * Self Pay Aetna CareFirst Cigna United Health Care Subscriber ID Number (Insurance ID) * Indicate N/A if you selected self-pay above Relationship to Subscriber: * Indicate N/A if you selected self-pay above Self Child Spouse N/A Other Dependent Subscriber Name & Date of Birth (If self, put N/A) * Indicate N/A if you selected self-pay above How Did You Hear About Empowerment Is Key? * Therapy for Black Girls Psychology Today Union Church Insurance Directory Other If Other, Explain Why Are You Seeking Therapy At This Time? * Thank you!