Book An Appointment To request an appointment, please fill out the form below: Client's First Name* Client's Last Name* Is the client a minor (under 18 years of age)?*Select an optionYesNoParent's First Name* Parent's Last Name* Email* Phone* Have you already spoken with our clinical director?*Select an optionYesNoWhat is your availability in the next 24 hours for a call back from our clinical director?* Please select your insurance*Select your insuranceSelf Pay1199 National Benefit FundAetnaAllied Benefit SystemCIGNAHorizon BCBS of NJ (NJ Direct)BCBS Out of State PlanAnthem BCBSEmpire BCBSHumana MilitaryIntervention StrategiesMagnacareMeritain Health CareOptumHealthUMRUnited HealthcareUnited Healthcare / OxfordOtherNo insuranceNot surePlease enter your specific insurance* Please enter your date of birth (or the date of birth of the client if they are a minor).* Policy Holder name* Policy Holder Date of Birth* Potential Client Name* Potential Client Date of Birth* ID Number* Group Number (if not sure, please enter N/A)* What kind of counseling are you seeking?*Select an optionIndividualCouplesChild/Play TherapyGroupOtherUnsureCombination of therapiesPlease indicate any applicable issues?* Anxiety Depression Stress Coping Skills Relationship Issues School Issues Parenting Divorce Life transitions Career Counseling Other Unsure Pregnancy & Postpartum Adolescent Girls' Issues Maternal Mental Health Issues Please enter other issue(s):* Do you know which of our therapists you would like to work with?*Select an optionYesNo, please choose the best fit for me.Please select the therapist you would like to work with.*Select an optionAllison Johnson, PH.D., LPC, PMH-CTaylor Henzel, M.ED., LPCGarth Nanni, M.S., LPCDawn Fuller, M.Ed., LPC, ACSDeborah Hamilton, M.S., LACShalaka Gupte, M.A., LPC, ACSMilly Balboa-Hart, MSW, LSWDeborah Flam, M.A., LAC, PMH-CSamantha Ellis, M.ED., LAC, NCCSamantha J. Herrick, Ph.D., LAC, CRC, NCC, ACSKaitlin Diaz, MSW, LSWTimothy Conway, MA, M.ED., LPC, NCC, ACSKelly Venezia Crilly, M.A., LAC, NCCMati Sicherer, Ed.D., LACBreanne Babin, M.A., LAC, NCCLaura Byrnes, M.Ed., LPC, NCCChristie Rossig, M.A., LAC, SACAlexis Green, M.A., LAC, NCCKatlyn Coggins, M.A., LAC, NCCMerritt Reid, M.S., LAC, NCCBrianna Himpele, MSW, LSWJessica Andresini, MA, LAC, NCCSharon Gbadamosi, MS, LAC, CRC, NCCWhen are you available for therapy sessions? (please include days and time frames of your availability)* How did you hear about us?*Select an optionPsychology TodayGoogle SearchGoogle MapsProfessional ReferralFriend / Family ReferralSchool ReferralSocial MediaOtherPlease specify how you heard about us.* Please enter the name of the professional you were referred by* Please enter the name of the school you were referred by* Tell us briefly (in 1 or 2 sentences) why you are seeking counseling services at this time?*
