NEW CLIENTAppointment Request We are only in network with BCBS PPO plans. Do you plan on using this insurance for your visit? * All therapists are in network with BCBS PPO plans with the exception of Lisa Pisha who is no longer accepting insurance. Yes, I do plan to use my BCBS PPO insurance No, I plan to pay the out of pocket session fee. Out of pocket session fees are $175 for the initial session and $150 for each additional session thereafter. Name * First Name Last Name Email * Can we email you? * Yes No Phone * (###) ### #### Can we call you? * Yes No What city & state do you live in? * City/State Are you seeking services for * Yourself Your Spouse/Partner Yourself + Spouse/Partner Your child Your family Other What brings you to therapy? * How did you hear about Grow Therapy Boutique? Is there a therapist you prefer to see? * Angela Michalak, MA, LCPC Kari Wittman Lata, MS, LCPC, LMFT Pam Caine, MSW Sarah Greene, MS, LCPC Deb Grizzell, MSW, LCSW Katie Scheer Dawson, MA, LCPC Lisa Pisha* (No longer accepting insurance. Please note session fees are $225/hour or $325/90 minute sessions with Lisa) No preference What is your availability? Select all that apply. Mornings (9a-12p) Afternoons (12p-5p) Evenings (5p-9p) Weekdays (M-F) Weekends (Sa-Su) Do you have a preference for in-person or teletherapy? * I prefer in-person I prefer teletherapy I have no preference Thank you for providing Grow Therapy with this information. Once we receive your submission, we will email or call you as soon as possible to further the process.
