Legal Name *

First Name

Last Name

Name You Go By *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Reason for Visit *

Why are you seeking care?

Family Conflict

Sexual Trauma

Stress Disorder

Attachment Disorders

Eating Disorder Addictions

Personality Disorders

Mood Disorders

Emotional Growth and Development

Pre-Marital

Prenatal Massage

Swedish Massage

Hot Stones

Medical/Neuromuscular Massage

Other

I would prefer if my practitioner was: *

No preference

Female

Male

I would prefer: *

In-person

Virtual

Insurance *

No Insurance (Self-Pay)

Aetna

United Healthcare

Blue Cross Blue Shield

Have insurance but open to sliding fee scale

Cigna/Evernorth

Other

Utilizing a community / employment partner

The Hive

Vital Connections

Girl Get Up Society

First Sun EAP

Lyra

Aetna EAP