Fill out the short questionnaire to help us hit the ground running on our call ⬇️

Step 1: Take The Short Quiz Below To Get Matched With The Right Therapist ⬇️

Takes Only 30 Seconds

Do you reside in the state of Florida? *

No

Yes

How soon are you hoping to begin therapy? *

As soon as possible

Within 1 week

I'm just exploring

We are a private pay therapy practice, and we do not accept insurance or medicaid *

I cannot afford private pay therapy at this time.

I understand, and i have a money budget my mental health goals.

First Name *

Last Name *

Email *

What is your mobile number? *

↓ I consent to data use described below

By checking the box above, I voluntarily authorize Be Your Best Self & Thrive., and service providers acting on its behalf, to share my name, email address, phone number, country, IP address, browser and device information, ad click identifiers, the web address of the page where I submitted this form, and the fact that I am inquiring about therapy services with Meta Platforms, Inc. (Facebook/Instagram) for advertising measurement and campaign optimization purposes. No diagnosis, symptoms, survey answers, or details about my care are shared. Checking this box is optional, and my ability to receive services is not conditioned on it. This authorization expires 12 months from the date I submit this form, or sooner if I revoke it. I may revoke this authorization at any time by sending a written request to [email protected]. Revocation will not affect information already shared before my request is received. Information shared with Meta may no longer be protected by HIPAA and may be redisclosed by Meta according to its own privacy policy. A copy of this authorization will be emailed to me.

By submitting this form, you acknowledge our Privacy Policy and consent to being contacted.

Step 1: Take The Short Quiz Below To Get Matched With The Right Therapist ⬇️

Takes Only 30 Seconds

Fill out the short questionnaire to help us

hit the ground running on our call ⬇️

Do you reside in the state of Florida? *

No

Yes

How soon are you hoping to begin therapy? *

As soon as possible

Within 1 week

I'm just exploring

We are a private pay therapy practice, and we do not accept insurance or medicaid *

I cannot afford private pay therapy at this time.

I understand, and i have a money budget my mental health goals.

First Name *

Last Name *

Email *

What is your mobile number? *

↓ I consent to data use described below

By checking the box above, I voluntarily authorize Be Your Best Self & Thrive., and service providers acting on its behalf, to share my name, email address, phone number, country, IP address, browser and device information, ad click identifiers, the web address of the page where I submitted this form, and the fact that I am inquiring about therapy services with Meta Platforms, Inc. (Facebook/Instagram) for advertising measurement and campaign optimization purposes. No diagnosis, symptoms, survey answers, or details about my care are shared. Checking this box is optional, and my ability to receive services is not conditioned on it. This authorization expires 12 months from the date I submit this form, or sooner if I revoke it. I may revoke this authorization at any time by sending a written request to [email protected]. Revocation will not affect information already shared before my request is received. Information shared with Meta may no longer be protected by HIPAA and may be redisclosed by Meta according to its own privacy policy. A copy of this authorization will be emailed to me.

By submitting this form, you acknowledge our Privacy Policy and consent to being contacted.

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