Contact | Ancora Wellness, Llc

Full Name

Birthday

Month

Day

Year

Phone

Email

Preferred method of contact

Phone

Text

Email

Are you a resident of RI?

Yes

No

**At this time, I can only accept RI residents.

Briefly explain your reason for seeking therapy

Do you have any of the following insurance options: BCBS RI, Optum (United), Tufts

Yes

No

I will be doing private pay

**Currently, those are the only insurance plans I accept. If you select no, please understand that you will be required to pay out of pocket. I can provide you with a Superbill for your insurance.

Please provides a few options for days and times for your availability

Preferred method for therapy

In person

Virtual

Hybrid

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