Brooke Hersh, Ph.D. | SimplePractice

Brooke Hersh, Ph.D. Send Message

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

Select the state you live in

Reason for care

What is the reason for seeking care?

Limited to 600 characters

What kind of care is being sought?

Individual Therapy Parent Coaching Other

What mental health care has been part of your experience?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past

I understand that availability is limited and this inquiry does not establish me as a client..

Yes

Administrative

Referral source

Who referred you to our services?

Billing & Payment

Payment details

Dr. Hersh is in-network with Aetna and BCBS. Superbills can be provided upon request.

Private Pay Aetna BCBS

Client Preferences

Availability

I have flexibility for a daytime appointment. I only have evening availability.

Preferred modality

In-person Telehealth Either depending on schedule

Is there anything that would be helpful for Dr. Hersh to know?

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.