First Name *

Last Name *

Email *

Phone *

Please indicate the type of services you are seeking and which therapist you'd prefer to work with. *

If seeking therapy services, what is your date of birth or date of birth of potential client? Put N/A if not seeking therapy. *

Do you plan to use insurance or pay out-of-pocket? If not applicable, put N/A. *

We currently accept Blue Cross Blue Shield PPO, Aetna PPO, Optum PPO, and United Healthcare PPO. If using insurance, please state the type of insurance you have, your Member ID and Group Number for a quick insurance verification check.

How did you find out about us? *

Can you briefly state what you'd like to work on? *

Messaging Consent

By providing your phone number, you agree to receive text messages from Coral Heart Counseling. Message and data rates may apply. Message frequency varies. Reply STOP to opt out.