Name *

First Name

Last Name

Phone *

(###)

###

####

Contact Preference

Which is your preferred contact method?

Email

Phone

Both

Subject *

I am interested in therapy at the PCMBH

I am interested in groups at the PCMBH

I am interested in medical case management at the PCMBH

I am interested in multiple services (individual therapy, groups) at PCMBH

I am interested in receiving consultancy, continuing education, or supervision from PCMBH / TLP Consulting

I am interested in working or interning at PCMBH (resumés should be linked, no upload available)

I have another inquiry for the PCMBH

Clinician & Coach Preference(s)

Louise Profit

J. Franco

Caroline Black (Telehealth only)

Yvette Murry (Telehealth only)

Michael Simon (Telehealth only)

Rita Stapleton

Aliza Auslander

Ariel Meltzer (Telehealth only)

Samson Gordon (Telehealth only)

Angela Konin

Victoria Martin (Telehealth only)

Joe Gandarillas

Anthony Mack (Coach)

Tracey Post

Eboni Gadson

Ross Griswold (Telehealth only)

Fakrat Alapa

Insurance *

NOTE: We are out-of-network with all insurance providers except for Blue Cross Blue Shield, Medicare Part B of New Jersey and Princeton University's EPN for Students (we are out-of-network for the staff and faculty's plan). Clients with other insurance are often able to submit for out-of-network reimbursement, depending on their individual policy. Uninsured clients may qualify for aid. Coaching is ordinarily NOT covered by any insurance unless a specific reimbursement fund exists for gender-transition related costs which are "non-medical". Our providers paneled with Medicare Part B of NJ are currently all at full capacity and cannot accept new clients. Medicare clients may see an out-of-network provider at our practice, but we cannot guarantee Medicare will reimburse.

Yes, I am enrolled as a student at Princeton University AND have Princeton University's Student Health Plan.

Yes, I am enrolled in Medicare Part B of NJ (Traditional Medicare)

No, I am seeking out-of-network care

Yes, I am enrolled in Blue Cross Blue Shield

Clinical Goals, Modalities & Preferences

Please select any that apply to you. If you would like to specify something that is not listed, please add it to your written message.

Cognitive Behavioral Therapy (CBT)

Internal Family Systems (IFS)

Somatic Experiencing (SE)

EMDR

Trauma-Informed Care

Deaf / Hard of Hearing (D/HH)

Couples & Relationship Counseling

Monogamous & Polyamorous Relationships

BIPOC

LGBTQ+

Adolescent

Anxiety

Depression

Gender

Sexuality

Neurodiversity

WPATH Letter

Grief

PTSD

Chronic Pain

Stress

In-person only

Virtual only

Virtual or in-person

Disclaimer *

DISCLAIMER: In utilizing this inquiry form, I hereby agree to accept a response via one or both of the communication methods listed above and assume sole liability for anything, including Protected Health Information (PHI) contained in this email exchange. I have chosen voluntarily to solicit an online inquiry for convenience of access. I understand that email may not be a secure form of communication to enclose PHI if my account is not covered by a BAA agreement with my email provider. I understand that submitting an inquiry does NOT create a client-provider relationship.

Yes, I (named above) agree to the disclaimer