Your first name
*
Your last name
*
Phone
Email
*
Address
*
Zip code
*
I am most interested in the following services:
Choose all that apply
Individual therapy
Couples therapy
Family therapy
Parent guidance
Group therapy
Neuropsychological assessment
No elements found. Consider changing the search query.
List is empty.
Will services involve anyone under 18?
*
Yes (as a client or focus of treatment)
No
Briefly share your primary concern.
*
What is the best way to reach you about scheduling?
You can choose multiple
Phone
Email
Text Message
No elements found. Consider changing the search query.
List is empty.
How do you plan to pay for services?
*
Select one
Self-pay
Blue Cross Blue Shield PPO
Aetna PPO
Other commercial insurance (out of network)
I need information on sliding scale rates
No elements found. Consider changing the search query.
List is empty.
If you’d like us to check your benefits prior to our call, include your insurance information:
Member ID
Group ID
Client name
Client date of birth
Primary insured name
Primary insured date of birth
How did you hear about us?
Select one
Google
Google Maps
ChatGPT
Insurance Plan
Doctor
School Counselor
Friend / Family
Other
No elements found. Consider changing the search query.
List is empty.
Initial Contact Disclaimer
*
Submitting this form and scheduling a consultation does not establish a treatment relationship. Psychological services begin only after an intake appointment and mutual agreement to proceed. This form is for scheduling purposes only.
Email and SMS Text Message Risk Acknowledgement and Use Consent
*
I consent to NKPsych contacting me about appointments and services using the phone, email, and/or text information I provide. I understand that electronic communications are not fully secure. This consent is limited to scheduling and administrative communications related to my care.
Submit