Name *

First Name

Last Name

Phone *

(###)

###

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Insurance:

Evernorth/Cigna

Optum/United Healthcare

Medicaid (Nebraska Only)

Other:

Therapy Service *

Individual Therapy

Accelerated Resolution Therapy (ART)

In My "Building My OWN Private Practice" ERA

In My “Support in My Private Practice” ERA

In My "Getting YOUR Flamingo Pink Back" ERA

Coaching

Sandtray Therapy

Requesting sliding scale for Individual Therapy

Requesting sliding scale for Accelerated Resolution Therapy