Name *

First Name

Last Name

I am interested in: *

Video appointment (anywhere in Colorado)

In-person appointment (Lakewood, CO)

Unsure / Either

I'd like to discuss counseling for: *

Myself

Me and my partner

My child (under age 10)

My child (age 10 and over)

What is the preferred way for us to contact you? *

Email

Text

Phone call

How do you plan to pay for sessions? *

Please note that we do not bill any insurance companies, with the exception of Colorado Medicaid, at this time.

I plan to pay out of pocket

I plan to pay out of pocket, and am in need of reduced rate sessions

I plan to pay out of pocket, and will submit bills to my insurance for out-of-network reimbursement

Colorado Medicaid (CCHA, Colorado Access, or Rocky Mountain Health Plans)

VEST EAP Program