Name *

First Name

Last Name

Telephone number where we may call and leave a message , if needed *

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I am interested in: *

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Scheduling an appointment with Bethany Pritchett

Scheduling an appointment with Chip Garrett

The waiting list for Elise Ezelle (currently more than two months)

The waiting list for Heather MacLeod (currently more than two months)

I am requesting information about services other than counseling

The counseling services are being requested for: *

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Myself

My child

Another adult

I am requesting information about services other than counseling

Insurance (if seeking counseling): *

Blue Cross Blue Shield (any state)

Cigna/Evernorth

ComPsych (EAP & insurance)

Medicaid - Alabama only

Medicare B

United Healthcare (including EAP, Optum, UMR, etc.))

Uprise Health (EAP & insurance)

Other insurance

Private pay

I am requesting information about services other than counseling