Request a Therapy Appointment

Name *

First Name

Last Name

Phone (if ok to leave message)

(###)

###

####

Insurance Information

Please select from our list of in-network insurance options. We provide claim forms upon request for out of network clients to submit to their insurance company after payment.

Anthem or Blue Cross Blue Shield

MaineHealth Employee Ins.

Community Health Options

Harvard Pilgrim

Martin's Point Generations Advantage

United Behavioral Health

US Family Health Plan

Out of Network

Type of Appointment-check all that apply

Please see separate appointment request link for any medication management requests.

Individual Therapy (age 18 or older)

Online DBT Skills Group (9 month commitment)

Online Adult ADHD Groups

Online Insomnia Treatment Group

Online Trauma Recovery Group

Emotional Support Animal Evaluation

Parent Coaching Services (self pay)

Preferred Location

Teletherapy sessions only

I am open to in-person AND teletherapy sessions (choose locations below)

In-person sessions only (choose locations below)

Brunswick

Portland

Bangor

Referral Source

Please let us know how you learned about our office.

Psychology Today

Website

Family or friend

Colleague

Primary Care Physician

Another therapist

I'm a current PSM client

I'm a former PSM client