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 to our New Client Coordinator?*Select an optionYesNoWhat is your availability in the next 24 hours for a call back from our New Client Coordinator?* Please select your insurance*Select your insuranceSelf Pay1199 National Benefit FundAetnaAllied Benefit SystemCIGNAHorizon BCBS of NJ (NJ Direct)Horizon Direct AccessHorizon BCBS Federal PlanHorizon BCBS Out of State PlanHorizon NJ Family CareHorizon OmniaAnthem 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)* Optional: Upload insurance card front/back to verify your insurance benefitsFrontMax. file size: 256 MB.BackMax. file size: 256 MB.What state do you reside in?*Select your stateNew Jersey (NJ)New York (NY)Pennsylvania (PA)Connecticut (CT)Florida (FL)California (CA)OtherWhat city / town do you live in?* Please enter the state and city / town you reside in:* What kind of counseling are you seeking?*Select an optionIndividualCouplesChild/Play TherapyInfertility, Pregnancy / Loss, PostpartumGroupOtherUnsureCombination of therapiesPlease enter the following information for both partners:Partner One:First Name* Last Name* Email* Phone* Date of Birth* Partner Two:First Name* Last Name* Email* Phone* Date of Birth* Please 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., LPC, ACSDawn Fuller, M.Ed., LPC, ACS, PMH-CDeborah Hamilton, M.S., LACShalaka Gupte, M.A., LPC, ACS, PMH-CDeborah Flam, M.A., LPC, PMH-CSamantha Ellis, M.Ed., LAC, NCC, PMH-CSamantha Herrick, Ph.D, LPC, CRC, NCC, ACSKaitlin Diaz, MSW, LSWTimothy Conway, MA, M.ED., LPC, NCC, ACSKelly Venezia Crilly, M.A., LAC, NCCMati Sicherer, Ed.D., LACLaura Byrnes, M.Ed., LPC, NCC, PMH-CChristie Rossig, M.A., LAC, SACMerritt Reid, M.S., LPC, NCC, PMH-CBrianna Himpele, MSW, LSWJessica Andresini, MA, LAC, NCCDanielle Slavin, MSW, LSW, PMH-CJanel Blake, MSW, LSWMaria Fagan, M.ED., LAC, NCCKatherine Rella, MSW, LCSWDawn DiMaria, MSW, LSW, VSW, CGPHannah Donner, M.Ed., LACErin Murphy-Wilczek, MSW, LCSWKimberly Perez-Lucero, M.A., LACAlexa DeJoseph, M.A., LACTari Miller, M.A., LPCWhen 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?*CAPTCHA
