Welcome to Empowered Mind Body Therapy

We would want your enquiry process to be as smooth and efficient as possible. Please complete this form so we can direct you to a clinician that will best fit your needs.

1. When would you like to start therapy?

2. Please provide preferable day and time of the week that works best for you on a recurring basis.

Appointment Type: TeleHealth AppointmentIn Person Appointment

3. Please select your insurance plan:

4.Member ID:

5. Group ID:

6. Are you the primary subscriber? If no, relationship to subscriber:

7. Primary Subscriber ID:

8. Primary Subscriber's Date of Birth:

9. Zip code listed with insurance company:

10. Are you seeking a specific modality of treatment? If so, please select:

11. Your name

12. Your Date of Birth:

13. Your email:

14. Your Phone Number:

At this time our group practice does not offer psychiatry, medication management, one-time evaluations or crisis services. If you are in crisis, please go to your nearest ER or call 1-800-273-8255