Your name:
*
First Name
Last Name
What state do you live in? (If your state is not listed, then we are not licensed to provide therapy in your location at this time.)
*
Alabama
Arizona
Arkansas
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Idaho
Illinois
Indiana
Kansas
Kentucky
Maine
Maryland
Michigan
Minnesota
Mississippi
Missouri
Nebraska
Nevada
New Hampshire
New Jersey
North Carolina
North Dakota
Ohio
Oklahoma
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Washington
West Virginia
Wisconsin
Wyoming
I am interested in:
Individual therapy
Couples therapy
Family therapy
I would like to work with:
No preference
Lillian Babcock, LPC
Theresa Butler, LPC, CAADC, NCC
Elizabeth Hahn, LCSW
Bonnie Jantzen, LAC
Lydia Jordan, LCSW, LCADC
Dr. Elizabeth Pearce, PsyD
Briefly, what brings you to therapy at this time?
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Your email address:
*
Your phone number:
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(###)
###
####
Ok to leave detailed voicemail at this number?
Yes
No
What is your preferred way for us to contact you?
Email
Phone
We are Out of Network with insurances, believing this enables us to provide the best care and ensure your privacy.
*
I understand that I will be working with an Out of Network therapist, that I am responsible for all session fees at the time of service, and that I will submit my own claims to insurance for possible Out of Network reimbursement.
Do you have any type of Medicare insurance plan?
*
GBH therapists do not participate with Medicare plans. Most therapists at GBH are opted out from Medicare altogether. You will be asked to sign a Medicare waiver and private contract to pay for sessions out of pocket, and will not receive super bills to submit to insurance.
Yes, I have a Medicare plan, and understand that I will waive Medicare benefits and enter a private contract for self-pay services at GBH.
No, I do not have any type of Medicare plan.
Do you have a Medicaid (state insurance) plan?
*
GBH therapists do not participate with Medicaid. New Jersey Medicaid plans will not reimburse you for any GBH-provided services.
*Medicaid laws may vary in other states, and so we do not work with Medicaid beneficiaries outside of New Jersey.
Yes, I have a NJ FamilyCare/Medicaid plan and understand that Medicaid will not reimburse me for any session fees.
No, I do not have a NJ FamilyCare/Medicaid plan.
Yes, I have a Medicaid plan in a state other than New Jersey.
Finally, how did you hear about Grace Behavioral Health?
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Google/Internet search
Psychology Today
Focus on the Family
AACC/Christian Care Connect
TheraVive Directory
GoodTherapy Directory
Friend or family
Another professional (physician, psychiatrist, etc.)
Office is convenient/noticed while driving by
Other
Thank you for getting in touch! You’ll hear from Jenn, our Administrative Coordinator, within about 24 hours (excluding weekends and holidays). She may gather a bit more information, answer any questions, and will connect you with just the right therapist for your needs.
We look forward to connecting!