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CONTACT US

All prospective patients must
complete this form.

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First Name

Last Name

Phone

Age

Service(s) of Interest: * Required

Individual Therapy

Adolescent / Teen Therapy

Couples Therapy

Family Therapy

Therapist(s) of Interest:

Leah Marcusen

Samantha Bernard

Heather Hoskin

Dr. Rachel White

I'm Not Sure

Payment for Services * Required

Private Pay

Aetna

Cigna

Lyra

Intern Rates ($20-40/session)

Compsych (Tiger Act), for applicable Law Enforcement members

First Responder Benefits (EAP or Tiger Act)

I would like more information

Other

**Please be aware that we are not in network with any

other insurances, other than those that are listed above.

**Due to need for medical diagnosis, we do not bill Aetna for couples therapy. Couples therapy is eligible to be covered by Lyra, Tiger Act, and PSCS benefits.

**RPS does not offer Superbills

I'm Working On:

Anxiety

Depression

OCD

Relationship Issues

Infidelity

Parent-Child Relationship Issues

First Responder / Military Issues

Perfectionism / People-Pleasing

Burnout / Overwhelm

Grief / Loss

Life Transitions / Adjustment

Self-Harm

Trauma

Workplace Issues

Other

Indicate Preferred Days / Times:

Mornings

Evenings

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

How Did You Hear About Us? * Required

I am a previous patient

Friend / Co-Worker

Therapist

Doctor / Psychiatrist

TikTok

Instagram

Facebook

Church

Public Safety Crisis Solutions

Other

Message

If seeking couples therapy, please include the full name and email address of your partner. When scheduling, you both will receive access to complete the intake forms.

If seeking therapy for a minor, please include the full name and email address of the other parent.

Thank you! Please look for our EMAIL contact within the next 24 hours!