Name

Date of Birth

Gender Identity Gender IdentityMaleFemaleTransgenderNon BinaryGender FluidOther

*Address

Phone Number

Best Time to Call Best Time to CallAMPMAnytime

Email Address

Which Clinician would you like to work with? Which Clinician would you like to work with?First Available ClinicianJerrica Raspberry Lawson, LICSWTiffany Cooper, LICSWKrystal Garcia, MA, R-DMTDaphne Cruz-Baez, MSWZarinah Gray, MSWLisa Laguerre, MS

Presenting Concern Presenting Concern Depression Anxiety Trauma Bipolar Disorder Grief Domestic Violence Parenting Sexual Trauma LGBTQIA Racial Trauma Racial Identity Eating Disorders Relationships Family Dynamics Workplace Concerns School Concerns Couples

Insurance InsuranceSelf PayBlue Cross Blue ShieldAllways Health PartnersUnitedHealthcare (UHC/UBH)UMROptum ProductHarvard Pilgrim

Service Type Service TypeIndividualCouplesFamily TherapyGroup

Schedule Availability Schedule AvailabilityMornings (9am - Noon)Afternoons (Noon - 4pm)Evenings (5pm - 7pm)First Available

How did you hear about us? How did you hear about us?WebsiteFacebookInstagramInnopsychTherapy for Black GirlsClinicians of ColorPsychology TodayLinkedInTherapy for LatinxOther