initial consultation form please fill out the following form to confirm your free consultation! Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name: *FirstLastEmail: *Phone Number: *Age: *Address: *Requested Therapist *Which therapist would you prefer to see?Ludley Howard (takes Blue Cross Blue Shield)Adrian V. Burnim (does not take insurance)Jason Rhodes (does not take insurance)Joshua Tassler (takes Blue Cross Blue Shield)No PreferencePresenting problem: *Scheduling preferences: *MorningAfternoonEveningWeekendsWeekdayschoose all that applyMethod of payment: *Out of PocketBlue Cross / Blue ShieldFlexible Spending AccountOnly if the client is a minor: First and last name of guardian and relationship to the childSubmit
