Clinical Counseling Inquiry Form INQUIRY FORM First and Last Name(required) Name of Person You Are Submitting For(required) Age of Person You Are Submitting For(required) Best Contact Email(required) Phone Number Clinical sessions can be charged through insurance, or paid out-of-pocket. Insurance Plan Type/Name We are providers with BCBSVT and VT Medicaid.(required) Out-of-Pocket Payment Option: ( Yes/ No/Maybe) (required) What town do you live In?(required) How did you hear about us?(required) What are your hopes in working with us?(required) Is there anything else you would like us to know? Submit Inquiry Δ
