Name *

First Name

Last Name

Phone *

(###)

###

####

Insurance Provider *

BCBS/BlueCross BlueShield PPO

BCBS/BlueCross BlueShield Blue Choice Preferred

Health Alliance

Humana

OSF Direct Access Network

UHC Caterpillar

United Healthcare UHC

UMR

My insurance is not listed.

I prefer to pay out of pocket for my services.

I am interested in counseling for (check ALL that apply): *

Adults

Children (under age 5)

Children (age 6-12)

Adolescents (age 13-17)

Marriage or Couples

Play Therapy

EMDR or Trauma Therapy

Families

Something Not Listed Here

Counselor Preference? *

ASAP - I would like the first person available.

I am not sure. I would like to talk to someone to help me decide.

Regina Bridges, MA, LCPC

Linda Cherry, MS, LCPC

Julie Cummings, MSW, LCSW, RN

Andrea Desatnick, MA, LCPC

Hannah Dobson, MA, ALMFT

Robin Hayles, MA, LCPC

Greta Long, BS, MA (in progress)

Michelle Matzke, MA, LCPC

Kate Mills, MA, LPC

Nathaniel Oldenburg, MA, LCPC

Jayshree Panchal, MA, LCPC

Erica Ray, MEd, LCPC

Dr. Courtney Stivers, PhD, LMFT

Dr. Ryan Stivers, PhD, LMFT

Joy Wolf, MSW, LCSW

Kaylee Yates, MA, ALMFT