What are you looking for?

Individual Therapy
Couples Therapy
Family Therapy

Name

First

Last

Preferred Name

Phone

Date of Birth

Email

Checkboxes

Any
Aradhana Walker
Yingning Wang
Rebecca Swanney

Name Phone Checkboxes

What goals do you hope to achieve?

What are your scheduling preferences for weekly sessions?

Which state are you physically located in?

Illinois
Washington, D.C.

Address

Address Line 1

City

State

Zip Code

Are you looking for online or in-person care?

Telehealth
In-person

You may choose both. We have only virtual availability for Washington, D.C.

Member ID

Group Number

Policy Holder's Name

Primary Subscriber

Insurance Card

Click or drag files to this area to upload. You can upload up to 2 files.

Please only upload photos of your insurance card.

Relationship to the Policy Holder

Self
Parent
Significant Other or Spouse

Policy Holder's Address

Address Line 1

City

State

Zip Code

Policy Holder's Date of Birth

Policy Holder's Phone

Acknowledgements

I agree with Roamers Therapy’s Fee Schedule and Policies.

Click here to read our Fee Schedule and Policies.

Checkboxes

I am currently an Illinois or Washington, D.C. resident.

Checkboxes

I am an adult (18 years old or older).

Government ID (front and back)

Click or drag files to this area to upload. You can upload up to 2 files.

e.g., Driver’s License, State ID card, Passport Card, Passport first page, or similar.