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Name *

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Email *

Phone Number *

Are you looking for therapy for yourself? *

Yes On behalf of a minor in my care No (Please explain below)

What is the reason you are seeking counseling? Is there something specific, such as a particular event? When did this start or happen? Please provide details to make sure that it would be a good match and I am able to meet your needs at this time. *

I am currently providing virtual telehealth appointments only. *

I prefer virtual appointments If this changes, I would prefer office-based appointments

Please note that I am only available for appointments between 10am and 4pm at this time, with some minimal availability outside of these hours. Are you able to make this work for your schedule? *

Yes No Sometimes

What is your insurance carrier? If you are not planning on using insurance benefits, please write N/A *

How did you find me as your therapist (e.g. insurance provider, friend, doctor referral, social media, Google search, provider directory search, etc.)? *

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