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Name of Parent/Guardian (If submitting for a minor)

First Name

Last Name

Which type(s) of therapy are you interested in? *

Individual

Couples

Family

Texting

I agree to receive text messages from EBC

Preferred clinician you’d like to see *

Robert

Jenny

Catherine

Any Body

If you plan on using insurance please select from the options below?

Blue Cross Blue Shield (for Robert or Jenny)

Aetna (for Robert or Jenny)

United (for Robert)

MultiPlan (for Jenny)

Are you OK with virtual sessions? *

Yes

No

Ugh/Yes, if I have to but I prefer in-person

Would you like to be added to our monthly newsletter? *

Yes, please!

No, thank you: I’m behind on emails as it is

I agree to my personal health information being accessed and stored securely by Every Body Counseling. *

Yes, I agree