Step 1. Share Your Information This form helps us set up your secure client portal so you can complete paperwork and move forward with scheduling Full Name * First Name Last Name Email * Phone * (###) ### #### State of Residence * Delaware Florida Texas Vermont Insurance Provider (or Self-pay) * Aetna Ambetter BCBS Fl Blue BCBS of Texas Cigna Oscar Health UHC UMR Self-pay Other Appointment Type * Free Consultation (15 minutes) Individual Therapy Couples Therapy Sex Therapy Addictions Counseling Other Preferred Day/time * Weekdays Weekends Any Time or Day How Did You Hear About Us? Psychology Today Grow Therapy/Headway/Sondermind/Tava Insurance Directory Google Search Social Media (Instagram/Facebook/Tiktok) Referral from Friend or Family Referral from Therapist or Doctor Healing Beyond Shame Network Workshop/Event/Flyer Other Thank you for submitting your information!You’ll soon receive an email invitation to the Let’s Talk Openly client portal. Please use that link to complete your intake and consent forms within 24–48 hours.Important: Appointments cannot be scheduled or confirmed until forms are completed (and insurance verified, if applicable).If you have any questions in the meantime, please feel free to reach out to us at admin@letstalkopenly.com.We look forward to supporting you on your journey.
