Secure Contact Form

Important Information

If you feel you are in need of urgent help or you are in crisis please visit your local hospital or call 911. In addition the below resources provide confidential support 24/7.

Suicide Prevention Lifeline 988
Trans Lifeline 1-877-565‑8860
The Trevor Project 1-800-246‑7743
Crisis Text Line - Text HOME to 741741

First name

Last name

Email address

Phone number

Message: Briefly explain your reason for contacting me:

Today's Date:

Please provide the best time to contact you and/or a date in which you would like to scheduled your consultation. Consultations are conducted:

Monday - Thursday 11:00 am, 2:15 pm, 5:45 pm, and 7:00 pm

Friday: 9:00 am, 1:00 pm, 2:15 pm, 5:45 pm, and 7:00 pm

Please note the above times may not always be available if someone has scheduled a consultation previously. However, I will attempt to accommodate you but if I cannot I will reach out to provide a specific dates and times that are available.

Best time to Contact you

Do you have a specific date you wish to have the consultation

Please note if this date and time is available you will be scheduled and sent a reminder prior to your appointment

Time you request for the consultation

How can I help? All therapy sessions are provided virtually

Individual Therapy

Select for Individual Counseling Inquiries

Group Therapy

Select for Group counseling Inquires

Couples/Marital Therapy

Select for couples/marital counseling inquires

How are you hoping to pay for therapy

Out-of-pocket

Insurance

Please provide type of insurance below

Name of Insurance Carrier: i.e. United Health Care, Aetna etc.

If you are interested in group therapy please select the type of group therapy you are interested in:

Setting Boundaries

Coping with the aftermath of domestic abuse

Improving Self-care

Improving Self-esteem/confidence

Parental issues

Speaker request on Mental Health Issues

Guest Speaker

If you'd like me to be a guest on your podcast or in person/virtual event

Upon submitting this form, any correspondence with you will require a password to ensure your privacy. Providing me with a question and an answer that only you will know helps to ensure your privacy through encrypted email and lets me know I am communicating with the correct person via phone or video conferencing.

Here are two examples of a question you may choose to provide. (i.e. What is my mother's middle name? or Who is my favorite superhero?) However, choose a question and answer that is easy for you to remember but only you will know.

Question:

Answer:

By submitting this information I give Bertha Barrett permission to contact me vial email or phone

I am 18 years or older

Your information will be encrypted.

Secure Contact Form

Important Information

Important Information

Intake Psychotherapy & Wellness, LLC