Join the Wait List! Name * First Name Last Name Email * Phone Number * Therapist Preference? * No preference Kelly Ready Kristina Works Robert Flowers Rowan Schoales Natalie Pascale Mike Lyons Natalie Melka NC Hardy Affordable Counseling Program (Therapist Intern) Method of Payment for Therapy Services (**please note** - if the insurance is not listed, Ignite is not in network) * Self Pay Cigna CO Access Medicaid RMHP Medicaid Kaiser UHC What brings you to Ignite? * OCD Concerns Trauma / PTSD Substance Use Concerns Life Transitions Impulse control concerns Grief and Loss Perinatal and Postpartum Parenting Mood, Anxiety, Depression Other (please elaborate below): Ketamine Integration Psychotherapy (if you have a current Ketamine prescriber, please note in Other, below): Other Details: Are you scheduling on behalf of someone else? If so, please indicate their name, age and contact information below. * If you are scheduling on your own behalf, please note "Self", below. Preferred Method of Communication * Phone Email How did you find us? * Referral from family or friend Referral from current therapist Internet Search Referral from doctor Insurance directory Google Ad Psychology Today or Therapeasy If referred by family, friend or your current therapist or MD, please include their name here. * Are you a current patient at a Ketamine provider? If so, please note the provider's name, here: Thank you! A member of our team will be in touch soon.
