test form Contact Form Name(Required) First Last Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth(Required) MM slash DD slash YYYY Gender Identity(Required)Please make a selectionFemaleMaleNon-BinaryGender FluidWish not to answerService Type(Required)Please make a selectionIndividual - AdultIndividual - MinorCouplesFamilyGroupImmigration EvaluationEMDRCouples Name #1(Required) First Last Couples Email #1(Required) Couples Name #2(Required) First Last Couples Email #2(Required) Family Family Member Name Family Member Email Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Parent/Guardian Name(Required) First Last Parent/Guardian Email(Required) Which Clinician would you like to work with? (Individual - Adult)(Required)Please make a selectionLisa Laguerre, MAKrystal Garcia, MA, R-DMTZarinah Gray, MSWDaphne Cruz-Baez, LCSWLisa Diaz, LICSWWhich Clinician would you like to work with? (Individual - Minor)(Required)Please make a selectionLisa Laguerre, MAKrystal Garcia, MA, R-DMTWhich Clinician would you like to work with? (Couples)(Required)Please make a selectionZarinah Gray, MSWDaphne Cruz-Baez, LCSWWhich Clinician would you like to work with? (Family)(Required)Please make a selectionLisa Laguerre, MAKrystal Garcia, MA, R-DMTWhich Clinician would you like to work with? (Group)(Required)Please make a selectionBenine Mudymba, LCSWWhich Clinician would you like to work with? (Immigration Evaluation)(Required)Please make a selectionBenine Mudymba, LCSWLisa Diaz, LICSWWhich Clinician would you like to work with? (EMDR)(Required)Please make a selectionLisa Diaz, LICSWPresenting Concern(Required) Anxiety Depression Substance Use Bipolar Trauma/PTSD Racial Trauma Eating Disorder Relationship Issues ADHD Anger Management Racial Identity Parenting Career Academics/Education Self Esteem Self Harm Suicide Codependency Coping Skills Sex Abuse Insomnia Domestic Violence Grief Infedilty Women's Issues Family Conflict Infertility Gender Identity Sexuality Peer Relationships Pregnancy, Prenatal, Post Partum Stress Insurance(Required)Please make a selectionSelf PayBlue Cross Blue ShieldAllways Health PartnersMass General BrighamUnitedHealthcare UHCUMRHarvard PilgrimOptumTuftsSchedule Availability(Required)Please make a selectionMornings (9am-12pm)Afternoons (12pm - 4pm)Evenings (4pm-6pm)How did you hear about us?(Required)Please make a selectionWebsiteFacebookInstagramLinkedInGoogle SearchOptumHarvard PilgrimBlue Cross Blue ShieldCare SolaceBoston UniversitySimmons UniversityNortheastern UniversityBoston CollegeBoston Public SchoolsBrigham and Womens HospitalBoston Medical CenterBrockton Neighborhood Health CenterUMass LowellSuffolk UniversityChildrens HospitalMass General HospitalOtherOther: How did you hear about us?(Required) *Due to state licensure and professional practice requirements, we can only take clients living and residing in the state of Massachusetts