Complete the form and we will be in touch within 48 hours

The form below will likely take you 5-6 minutes to complete. The more information you provide, the better we are able to match you with the right therapist to meet your needs!

A little information goes a long way...

a note about our appointment request form

Choosing a therapist is a very personal journey and here at GTA we do our best to make it as easy as possible. Our admin team is skilled at matching clients with the therapist who is the best possible fit on our team. And the information you provide on the form above is why.

If you prefer to choose for yourself, there’s an option to select your preferred therapist(s) below. Either way, we make it easy to get started.

Meet Our Therapists

Do you need immediate mental health help?

GTA is honored to support our community’s emotional wellness; however We are not a 24/7 emergency provider. If you or someone you care about are experiencing a mental health emergency please please call or text 988 or visit your local emergency room or crisis intervention unit.

1Contact Information

2Tell Us More About You

3Payment and Therapist Preferences

4Tell Us About Your Goals

First Name *

Last Name *

What state will physically be in during your teletherapy/online sessions? *

Primary Email *

Confirm Email

*Please list email address you want to use as primary point of contact. Registration and billing information will be sent to this email. If primary client is a minor, enter the parent/responsible party's email here.

Phone Number *

Are you comfortable with us leaving a message identifying ourselves as Group Therapy Associates at the phone number you provided?

Who is the primary client? *

*Please be sure to enter the PRIMARY CLIENT's name and date of birth above. If the primary client is a minor or you are interested in couples therapy, there will be space to enter parent or partner information below*

Date of Birth [primary client] *//

What are your preferred pronouns?

please respond on behalf of the primary client

Race and Ethnicity

Black
White
Asian
Hispanic / Latinx
Middle Eastern
African
European
Other
Prefer not to say
American Indian / Alaska Native
Native Hawaiian / Pacific Islander

please select as many as you identify with or none at all if you prefer not to share this information

How would you like to pay for services *

* please note * we are an in-network provider for CareFirst and Anthem Healthkeepers Plus plans ONLY * If you have another insurance provider we are happy to offer prepaid package discounts and assist you in submitting claims for out-of-network benefits.

If you'd like to you use insurance, please select your carrier below and provide your ID number: *

* please note * we are an in-network provider for CareFirst and Anthem Healthkeepers Plus plans ONLY * If you have another insurance provider such as Anthem BCBS, United, Aetna, etc. we are happy to offer prepaid package discounts and assist you in submitting claims for out-of-network benefits.

ID Number

providing your insurance subscriber information now expedites our ability to verify your coverage before scheduling

Group Number

Subscriber's Name

Subscriber's Date of Birth

Are you a member of The Yard Co-Working Space *

Preferred Location *

If you are open to being seen in multiple locations, please indicate that in the notes section on the next page.

Preferred Therapist (select up to 3 options) (VA - online) *

No preference / Help me decide
Fran Singson, Professional Counselor - Resident
Miriam Saleh, Professional Counselor - Resident
Maria Perozzi, LMFT
Taylor Wardle, MFT-R
Samantha Russell-Porte, LMFT
David Wen, PsyD
Chris Davies, LMFT