Schedule Now Is this scheduling request for a child under 18 years of age or for a family?*YesNoImportant!!! Unfortunately, our office is no longer providing adult therapy services. We will continue seeing children, adolescents and families. If you need adult, mental health, or substance abuse services, please go here.Child's Name* First Last Child's Date of Birth* Date Format: MM slash DD slash YYYY Name of Person completing Form First Last What is your relationship to the Child? Biological or Adoptive Parent Step Parent Foster Parent Other Guardian Other Phone*Email Preferred Time(s) of Day for Apt. Morning (8-10) Midday (11-1) Afternoon (2-4) Preferred Day(s) of the week Monday Tuesday Wednesday Thursday Services Requested Individual Therapy Group Therapy Family Therapy Co-Parenting Program Preferred Therapist No Preference C.J. Quick, LPCC-S, LMFT, RPT-S Beth Larimore, LPCC-S, RPT-S Sarah Reynolds, LCSW Chris Longoria, LCSW, RPT Krista Mitchell, LCSW, RPT Type of Insurance/Payer Anthem Blue Cross/Blue Shield Passport Humana CareSource Aetna Better Health of KY Wellcare of KY Aetna Humana United Health Care/UBH/UMR Cigna GEHA Tricare Medicaid Other Any additional Requests or Information you'd like us to know...