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What insurance do you have (put NA if you do not have any) *

What location do you prefer? Lexington, North Kentucky, or no preference? *

How would you like your appointment? In person, by Telehealth, or Both? *

Therapist Requests (do you have a preference as to which therapist you see, gender, or specialty?) *

Why are you seeking assistance? *

Please do not list specific medical concerns, or any personal or confidential information such as account numbers or credit card information.

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If this is an emergency, please call 911.

Or contact the National Suicide Prevention Lifeline at 1-800-273-TALK

New Vista Crisis Line at 1-800-928-8000