First Name* Last Name* Phone* Email* Preferred method of contact? Phone Email What services are you inquiring about?* Individual Therapy Couple's Counseling EMDR Career or Parent Coaching Children's Therapy Dance/Movement Therapy Other/Unsure Who would you like to see? Anyone Karlie Korish Yasna Shahbazi Caitlin Sparer Ashley Tokuda Christine Waisner Caitlyn Schmit Heather Deveny-Leggitt Paul Sevett Melissa Saari Andrea Scharlatt Pa Tou Vue Name of Insurance Company Health Partners Blue Cross Blue Shield Preferred One UCare Cigna Aetna Medica/UBH/UHC Medical Assistance Other Insurer Not Listed Policy Number Name of Insurance Company (secondary, if applicable) Health Partners Blue Cross Blue Shield Preferred One Cigna UCare Aetna Medica/UBH/UHC Medical Assistance Other Insurer Not Listed Policy Number (secondary insurance) Date of Birth What days/times are you generally available for therapy? Comments Please verify your request* Submit