New Client Evaluation

Click HERE for current policies.

* Accepting Aetna, Cigna, Humana, Tricare, and self pay only

*We do not accept Medicaid, Medicare or Medicare Advantage Plans*

* At this time, our services are provided only for residents of the following states:

Maryland, Nevada, Oregon, and Washington, D.C.

* If you reside in the states we serve, but wish to use the Talkspace platform:

*Please click here, to return to our home page for more information

Evaluations are reviewed during our normal business hours, Monday-Thursday 8AM - 4 PM CST (excluding major holidays). You will be contacted within one business day, regarding your submission.

Please double-check for accuracy: Spelling of first and last name, date of birth, and email address.

First Name

Last Name

DOB (Serving ages 18-65; as stated under Policies).

Phone Number

What insurance do you carry? (Please take time to review home page for the plans we accept.)

Please provide a brief statement explaining why you are seeking treatment. If you have current, or previous, psychiatric diagnoses, please list them here:

Have you been hospitalized for psychiatric reasons? If yes, briefly indicate when, and why:

List current psychiatric medications.

List previous psychiatric medications.

We have received your submission. You will hear from us within one business day.

Kuponya

Telepsychiatry

Kuponya... - Swahili.... English translation, "healing; to heal"

New Client Evaluation

Click HERE for current policies.

Evaluations are reviewed during our normal business hours, Monday-Thursday 8AM - 4 PM CST (excluding major holidays). You will be contacted within one business day, regarding your submission.

Please double-check for accuracy: Spelling of first and last name, date of birth, and email address.

​

​

New Client Evaluation

Click HERE for current policies.

​

​

​

Evaluations are reviewed during our normal business hours, Monday-Thursday 8AM - 4 PM CST (excluding major holidays). You will be contacted within one business day, regarding your submission.

Please double-check for accuracy: Spelling of first and last name, date of birth, and email address.