Contact Us Today Name * First Name Last Name Date of Birth * Email * Phone * (###) ### #### Insurance * Aetna Blue Cross Blue Shield Cigna/Evernorth United Healthcare TRICARE East Private Pay Preferred Method of Contact * Phone or Email Email Phone Subject * New Client Request Billing/Insurance Questions General Questions About Counseling If you are comfortable doing so, please share a little more about why you are seeking therapy so that we may better understand your needs: * By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Intrinsic Counseling and Treatment Center harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means. Yes, I want to submit this form Thank you! Your request has been submitted and we will be getting back to you as soon as possible.
