Name *

First Name

Last Name

Phone *

(###)

###

####

Which services are you interested in? *

Individual Therapy

Group Therapy

Couples / Family Therapy

Psychedelic Somatic Interactional Psychotherapy (PSIP)

Ketamine Assisted Psychotherapy

Psychedelic Integration

Functional Health Consulting

Yoga / Somatic Therapy

Intensive Therapy

Ampcoil / PEMF

Acupuncture

Where do you want services to take place? *

In person / In office

Online / Telehealth

Open to any option

Which clinician would you like to work with?

Lauren Ampolos, PhD

Amber Vantze, MFT, LMHC

Jamee Palomique, MS, LMHC

Becca Moriconi, LSW

Nicole Kastan, LSW

Vanessa Baggs, LSW

Joshua Levy, LAc

Open to working with an intern

Other (please share in the message box below)

Which payment option will work for you? *

Insurance (In-network only)

Insurance (Out of network okay)

Private / Cash pay

Which insurance do you have? *

Alohacare

BCBS

HMAA

HMSA Akamai Advantage

HMSA Commerical HMO

HMSA Commercial PPO

HMSA Quest

Kaiser (accepted only with referral)

'Ohana / Wellcare

UHA

No current insurance

Other (please specify in the message box below)