We are honored you feel we might be a fit to work with you and look forward to conversation about your needs. Please complete this short questionnaire and Vanessa, our practice manager, will be in touch with you to set up a session. Thank you!

Client's Name *

First Name

Last Name

Client's Age *

Parent Name (if you are the parent of a child who will be the client):

First Name

Last Name

E-mail *

Phone

(###)

###

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Tell us a bit about what you'd like to focus on in therapy. *

Insurance or Private Pay: Our providers are in-network with the panels listed below. If your insurance plan isn't listed here, it is because we are not an in-network provider. *

EMI

Select Health (Select Med, Choice, Value and Care ONLY)

PEHP (Advantage Network ONLY)

University of Utah Health Plans (Healthy Preferred, Healthy Premier, U Health Plus) Not in-network with Regence Plans

HMHI - BHN (Only Whitney Barrell, LCSW is in network)

Private Pay ($140 -$170 depending on provider)

Do you have a preference of which therapist you'd like to work with? *

Annie Hamilton, LCSW (openings on Tuesday mornings, Wednesday early afternoon)

M'Recia Seegmiller, CSW (openings on Monday afternoon, Tuesday evenings and Friday mornings/early afternoon)

Kara Bailey, ACHMC (openings on Tuesday, Wednesday or Thursday afternoon/evenings)

Whitney Barrell, LCSW (Monday or Wednesday mornings)

No preference