Self Scheduling - Direct Flow

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Let's get you booked in!

We just need a couple more details to book your initial consultation. Typically we have availability same-day. If you have any questions before booking, take a look at our FAQs
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intake_idIdentifier for intake flow: {FirstName_|_Email} If this is filled Name, Email will be hidden
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fbclidThis is a hidden field for tracking purposes only
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Where do you live?* This field is required.We only provide care in Texas
Texas
Please Select
Texas
Alabama
Alaska
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Washington
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Wyoming
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What's your date of birth?* This field is required.
Date of birth
Month
Day
Year
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
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American Samoa
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Angola
Anguilla
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Aruba
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Brunei
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Christmas Island
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Cook Islands
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Cote d'Ivoire
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Cuba
Curaçao
Cyprus
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Denmark
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Falkland Islands
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The Gambia
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Nigeria
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Poland
Portugal
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Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
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Samoa
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Senegal
Serbia
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South Ossetia
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eSwatini
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Other
Country
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Do any of the following apply to you?* This field is required.We may not be a good fit for certain conditions. If you are in an emergency or life-threatening situation, call the National Suicide Prevention Line at 1-800-273-8255 or dial *988, or go to the nearest emergency room.
Diagnosed with a primary psychotic disorder (e.g. schizophrenia, schizoaffective disorder, etc.)
None of the above
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What health insurance do you have?* This field is required.
Blue Cross Blue Shield
Anthem Blue Cross Blue Shield
Aetna
CIGNA
UnitedHealthcare
Optum
Medicare
Humana
ChampVA
Tricare
Magellan
Medicaid
Compsych EAP
Self-Pay
Other
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Please enter your primary insurance member ID number:* This field is required.This number can be found on your insurance card and will be labeled as 'member' or 'subscriber' ID number
If not applicable due to self-pay or other, please enter N/A
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Please enter your primary insurance group number:* This field is required.This number can be found on your insurance card and will be labeled as 'group' or 'GRP' number
If not applicable due to self-pay or other, please enter N/A
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Sex at birth
Male
Female
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Next, we need your phone number so we can send you texts about your care.* This field is required.By clicking 'Next', you consent for us to send you texts. Standard rates may apply.
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What's your email?* This field is required.
example@example.com
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What's your name?* This field is required.
First Name
Last Name
Should be Empty: