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Client's Name *

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Client's Date of Birth

Client's Phone Number

Client's Email Address *

What would you like our therapist to know? *

Payment Method *

• Cash / Private Pay
• Anthem Blue Cross Blue Shield
• Physicians Health Plan (PHP) of Northern Indiana
• Vãlenz Care
• Parkview Signature Care or Parkview Value Plus
• Lutheran Preferred / Three Rivers Preferred + / Lutheran Advanced
• Optum
• United Healthcare
• Medicaid
• Something Else

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I would like to: *

• Schedule an In-Office Session
• Schedule a Telehealth Session
• Have someone from At Your Pace Counseling, LLC to contact me.
• Be Placed on the Waitlist

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At Your Pace Counseling, LLC
Office Location:
4646 West Jefferson Blvd; Ste #270
Fort Wayne, IN 46804

Mailing Address:
5651 Coventry Lane; Ste #179
Fort Wayne, IN 46804

Phone (260)207-4241 | Fax (260) 201-9557

For questions about our therapy practices or policies please email: info@aypc.email

For questions about an invoice, email office@aypc.email

If you need assistance with scheduling a session, please email info@aypc.email

To inform us that you have to cancel your session, please email cancellations@aypc.email