Request a Therapy Appointment To request a therapy appointment, please fill out the form below with your information and press submit. Assurance Behavioral Healthcare Request a Therapy AppointmentName *Phone *Email *Date of Birth *Would you prefer *in persontelehealtheither is fineClinician Name (if known) Clinician specializing in: Gender Preference No PreferenceMaleFemaleDesired time of day OpenMorningAfternoonEveningWeekendInsurance Carrier Insurance ID # Additional information VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>: