First Name

Last Name

Phone *

Email *

Address

City

Postal code

Whom Are You Seeking Counseling For

How Would You Like To Receive Services

In-Person Only

Telehealth Only

Open to Both

Briefly Describe The Issue You Would Like to Work On

What Type of Therapy are you seeking?

Individual counseling

Couples counseling

Child counseling

Are you interested in your child or teen joining a social skills/ Self-esteem therapy group?

Are you hoping to use your insurance?

If you are wanting to use your insurance, What insurance do you have?

How did you hear about us?

Would you like to receive our best parenting and relationship advice sent to your email?

Provide 3 Times You Are Available for Counseling

What's the Best Way to Contact You?

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