Schedule Now Name* First Last Phone*Email Date of Birth* Preferred Time(s) of Day Morning (8-10) Midday (11-1) Afternoon (2-4) Evening (5-7) Preferred Day(s) of the week Monday Tuesday Wednesday Thursday Friday Services Requested Individual Therapy Group Therapy Family Therapy Case Management Couples Therapy Parenting Classes Co-Parenting Program Anger Management Program Batterer's Intervention Program (BIP) Women Who Use Force Group Program Substance Abuse Assessment Preferred Therapist No Preference C.J. Quick, LPCC-S, LMFT Beth Larimore, LPCC-S Sarah Reynolds, LCSW Kristin Kaster-Bratcher, LPCC Chris Longoria, LCSW Melissa Fincher, LPA Amanda Lee-Degner, LPCC-S Veness Hall, LPCC Madelyn Wise Kelley Fulkerson, CSW 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...