Request An Appointment - Embracing Oak Therapy

Name *

First

Last

Date of Birth *

Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Do You Have Insurance? If your insurance is not listed, then we are unable to accept it. *

Insurance Company *

Insurance ID – include all letters and numbers (put n/a if you are a self-pay client) *

Do You Have A Secondary Insurance Policy? *

Secondary Insurance Company *

Secondary Insurance ID – include all letters and numbers (put n/a if you do not have a secondary policy) *

Therapist *

Reason for Therapy *

Embracing Oak Therapy