I'm seeking therapy for

Child

Adult

Couple (Please see the note below)

I am seeking a one time ESA/or other assessment

In the spirit of transparency, we want you to know that we do not accept health insurance for couples therapy. Please read here why.

Your Name *

Date of birth *

What are your pronouns?

Email *

Phone Number *

Street Address *

City *

State *

Country *

Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People"S Republic
Korea, Republic of
Kuwait
Kyrgyzstan
Land Islands
Lao People"S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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Postal code *

Your Child's Information

Your Partner's Information

Partner's Phone Number

Partner's Email Address

Insurance Information

Do you desire to use insurance benefits? *

Yes

Insurance Sponsor's Name

Sex on file with insurance *

Female
Male
I am not using insurance
Other, contact me
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Insurance Provider

Name on File with Insurance

The insurance company needs the exact name they have on file for claims to be processed correctly.

Insurance ID

Your Insurance ID can be found on your insurance card, often labeled as Member ID or Subscriber ID. This is a unique number that helps your provider identify your specific policy. Check the front of your insurance card.

Group Number

The Group Number is a key number that identifies the specific group insurance plan provided by your employer or organization. You can typically find this near the Insurance ID on your card. Check the front of your insurance card.

Upload front of the insurance card

Upload back of the insurance card

Policyholder’s Date of Birth

If different than your date of birth

Policyholder’s Address

What services are you seeking? *

Choose all that apply

Individual Therapy
Family Therapy
Couples Therapy
Group Therapy
ESA or Other Assessment
Other
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What topics/issues are relevant to your needs? *

Choose all that apply

Anxiety/fear/panic/stress
Depression/sadness/low-mood/mood instability/
Trauma/PTSD/childhood trauma
Parenting
First responder related topics
Veteran/military
Neurodivergence
Autism
ADHD
Gottman Method
Cognitive Behavioral Therapy
Dialectical Behavioral Therapy
EMDR
Mindfulness
Art therapy
Hypnotherapy
Anger Management
Abuse (all types)
Intimate partner violence
Obsessive compulsiveness
Post-partum, peri-natal
Bipolar disorder
Disordered eating
Bullying
Stress management and mindfulness
Caregiver Fatigue
Immigration/1st Gen
Transgender related topics
Sex positive/kink allied
Midlife crisis
Gender identity
Post abortion
Adoption
LGBTQIA+
Non-substance addiction
Self esteem
Sex drive/libido
HIV/AIDS
Grief or loss
Self harm
Chronic illness
Chronic pain
Somatic symptoms
Family of origin issues
Polyamorous/ Non-monagamous
Dissociative disorders
Internal family systems
Polyvagal theory
Body image
Senior/mature individuals
Porn concerns
Identity persecution
Divorce mediation
Sexual dysfunction
Infertility
Other(s)
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What therapists are you open to working with? *

Choose all that apply

Any therapist that may fit my needs (i.e., in network with my insurance, available when I am, able to help with the things I want to work on)
Barry Whetstone, LCSW
Bethany Williams, LPC
Chris Avila, LCSW-S, BCD
Delisea Johnson, LCSW
Jasmin Washington, LCSW
Je’Nae Kelley, LPC
Jennifer Cotton, LPC
Jordan Sanders, LCSW
Nicole Anderson, LPC
Sabrina Carrington, LCSW
Shirlecia Dickson, LPC
Karissa Doster-Hoffman, LCSW-S
Vic Doster, PsyD, LCSW
Other
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If the therapist(s) you selected are not a good fit or are unavailable, how should we proceed? *

Match me with another therapist that is a good fit.

Contact me before attempting to match me with another therapist.

What does your availability look like for recurring therapy appointments, Monday through Sunday from 7am CST to 8pm CST? *

Please be as specific as possible, availability plays a big role in therapist matching. If you have flexibility, please let us know.

🛑 I agree to view the client consultation agreement that will be sent to me via the email included on this form upon submission. If there are contents in the client consultation agreement email that I do not understand, or if I do not receive the email, I will reach out to connect@bpoqe.org.

How did you hear about us?

We take your privacy and confidentiality seriously. All information submitted through this form is securely encrypted and used solely for the purpose of providing the best possible care. We adhere to strict privacy policies to ensure your personal and medical details are protected. Your data will never be shared with third parties without your explicit consent.