First name *

Last name *

Date of birth *

Are you inquiring about services for a child under the age of 18?

Yes

Note: we don’t provide services for anyone younger than age 14.

Child's first name

Child's last name

Child's date of birth

Phone *

Email *

What state are you located in? *

Are you looking for virtual or in-person services? *

Virtual

In-Person

Either

In case we don't have evening or weekend therapy slots at the moment, would you be available during regular business hours? *

Yes

Briefly describe why you are seeking services. *

Did you read our Self Pay Policy? *

Yes

We are out-of-network providers which means you will pay upfront for services, and then, as a courtesy, we submit a claim to the insurance company on your behalf — so you can be reimbursed for any money owed as part of your insurance plan. Most insurance companies that provide out-of-network benefits cover between 50%-75% of the cost per session.

Would you like us to look into your out-of-network benefits?

Yes

Are you the policy holder?

Yes

Please confirm you added your legal first and last name.

Policy holder legal first name

Policy holder legal last name

Policy holder zip code

Add a photo of the front and back of the insurance card

How did you hear about us? *

You can choose multiple

Word of mouth
Referral from another health provider
Online search
Google ad
Psychology Today
Therapy Den
Therapy for Black Girls
University Referral Database
Social Media
Other
No elements found. Consider changing the search query.
List is empty.

If you chose "referral from another health provider" above please type in the name of the provider

If you chose "other" please type in the person's name

Get our monthly newsletter with tips and updates from our therapists. (You can unsubscribe at any time.)

By submitting this form, I acknowledge and accept the risks of using email and electronic messaging to communicate my health information. I consent to New Connections Counseling Center office staff and therapists communicating with me via email or SMS text messages.