Please enable JavaScript in your browser to complete this form.Name *FirstLastPronounsEmail *If you prefer I call you instead of emailing you back, please enter your phone number:FinancialSelf PayI will self pay but need a superbill to submit to my insurance for out-of-network benefitsHow do you prefer to meet?In person at your officeVirtuallyWhen are you available?Flexible/Any day or timeI need a certain day or timePlease say the day or time you require if you don't have a flexible schedule:How often do you hope to be seen?weeklyevery-other-weekIf I don't have immediate availability, are you willing to be on a waiting list?Yes, for however long it takesYes, for 1-2 monthsNo, I need to be seen right awayWould you like me to send you referrals if I don't have the day or time you are looking for available?Yes, pleaseNo, I already have referralsWhat is bringing you in for counseling?Any other questions I can answer?Who referred you or how did you find me?Submit
