1 Alliance Counseling & Psychotherapy Services Send Message

Who would be receiving care?

Your info

Select the state you live in
Reason for care
Please note we do not work with Eating Disorders at this practice as it is best to seek specialized care.
Mark all options that apply. Note, FMLA - Family medical leave act. Disability such as short term disability, long term disability (private or government))
Administrative
Enter how you were referred to our services
Do not upload sensitive financial information such as credit card information.
Billing & Payment
How do you plan to pay?
Please list the name of your insurance company such as Aetna, Cigna, BCBS, United Health, Kaiser etc
Limited to 600 characters
Upload a photo of your insurance card
Client Preferences
Select a clinician from the list
For example: what you'd like to focus on, insurance or payment questions, etc.
Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.