Contact Us

Client Name *

First Name

Last Name

Client's Date of Birth *

MM

DD

YYYY

Caregiver Name (if applicable)

First Name

Last Name

Client or Caregiver Phone

(###)

###

####

Which clinician would you like to meet with?

Dr. Christine Hook (psychological testing only, ages 3-22)

Shelley Chambers (therapy & co-parenting, all ages)

Maddie Haddock (therapy, ages 7+)

Buffy Taylor (therapy, ages 25+)

Insurance Coverage * (Therapy Services Only)

*Please note the in-network providers next to the insurance company name. If your insurance is not listed, we are out of network.

BCBS (Shelley Chambers, Maddie Haddock, and Buffy Taylor)

Aetna (Shelley Chambers, Buffy Taylor, and Maddie Haddock)

Cigna (Buffy Taylor only)

United Healthcare (Buffy Taylor only)

Medicare Part B (Buffy Taylor only)

Tricare (Maddie Haddock only)

Custody Acknowledgement (for treatment of minors)

Is there any active or past court involvement regarding custody arrangements? Please note that we require all legal guardians to consent to treatment in the event of separation or divorce.

Yes

No