Your Name *

First Name

Last Name

Your child's name (if applicable)

First Name

Last Name

Date of Birth of Person Receiving Service *

Please share the date of birth of the person who will be receiving counseling. This is never shared regardless of whether or not we work together.

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DD

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Phone Number to Contact You

Please share a phone number you consent for me to contact you at.

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I am seeking care for:

Myself

My child

Preferred appointment type:

Telehealth

In-person (No openings currently)

What is your preferred method of contact regarding this inquiry? *

Email

Phone call

Text message

For payment, you plan to use *

$25/ session with Lizz

MaineCare

Anthem/ Blue Cross Blue Shield

Aetna

United Healthcare

Harvard Pilgrim

Maine Community Health Options

I consent to being contacted regarding this inquiry, through the preferred method I selected above. Please be sure to check your spam for a reply if email is your preferred contact method. *

Yes