Questions/Inquiries

I value your privacy. Please do not include any confidential or private information regarding your health condition in this contact form or any other form found on this website. This form is for general questions/inquiries only.

Name

First Name

Last Name

State (if not in USA, please provide country)

Phone

Best number to reach you to speak privately.

(###)

###

####

Email Address

I am interested in...

Therapy

Life Coaching

Workshop/Training

Other....please specify below

I plan to use Insurance (for therapy inquiries)

(BLUE CROSS BLUE SHIELD OF IL PPO PLANS & UNITED HEALTHCARE/OPTUM PPO INSURANCES ACCEPTED)

Yes, I have BCBS PPO plan or United Healthcare/Optum/UMR PPO plan.

No, I plan to pay out of pocket by using Credit/Debit card or HSA/FSA card for reimbursement due to out-of-network.

No, I plan to pay without insurance.

Additional message (optional)

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*Questions/Inquiries*

Questions/Inquiries