Name *

First Name

Last Name

Phone *

(###)

###

####

Contact Preference

Which is your preferred contact method?

Email

Phone

Both

Subject *

I am interested in therapy at the PCMBH

I am interested in groups at the PCMBH

I am interested in medical case management at the PCMBH

I am interested in multiple services (individual therapy, groups) at PCMBH

I am interested in receiving consultancy, continuing education, or supervision from PCMBH / TLP Consulting

I am interested in working or interning at PCMBH (resumés should be linked, no upload available)

I have another inquiry for the PCMBH

Clinician & Coach Preference(s)

Louise Profit

J. Franco

Caroline Black

Yvette Murry

Michael Simon (Telehealth only)

Rita Stapleton

Aliza Auslander

Ariel Meltzer

Samson Gordon (Intern)

Angela Konin

Victoria Sharkey

Joe Gandarillas

Anthony Mack (Coach)

Tracey Post (Currently not accepting new clients)

Eboni Gadson (Currently not accepting new clients)

Ross Griswold (Currently not accepting new clients)

Insurance *

NOTE: We are out-of-network with all insurance providers except for Medicare Part B of New Jersey and Princeton University's EPN for Students (we are out-of-network for the staff and faculty's plan). Clients with other insurance are often able to submit for out-of-network reimbursement, depending on their individual policy. Uninsured clients may qualify for aid. Coaching is ordinarily NOT covered by any insurance unless a specific reimbursement fund exists for gender-transition related costs which are "non-medical". Our providers paneled with Medicare Part B of NJ are currently all at full capacity and cannot accept new clients. Medicare clients may see an out-of-network provider at our practice, but we cannot guarantee Medicare will reimburse.

Yes, I am enrolled as a student at Princeton University AND have Princeton University's Student Health Plan.

Yes, I am enrolled in Medicare Part B of NJ (Traditional Medicare)

No, I am seeking out-of-network care

Disclaimer *

DISCLAIMER: In utilizing this inquiry form, I hereby agree to accept a response via one or both of the communication methods listed above and assume sole liability for anything, including Protected Health Information (PHI) contained in this email exchange. I have chosen voluntarily to solicit an online inquiry for convenience of access. I understand that email may not be a secure form of communication to enclose PHI if my account is not covered by a BAA agreement with my email provider. I understand that submitting an inquiry does NOT create a client-provider relationship.

Yes, I (named above) agree to the disclaimer