Name *

First Name

Last Name

Phone *

(###)

###

####

May I leave a voicemail at this number? *

Yes

No

May I text you at this number? *

Yes

No

If you are interested in therapy, please select your current therapy modality preference below (check all that apply) *

In-person only

Telehealth services

Hybrid of in-person and telehealth services

I have read the FAQ's and am aware of costs and that insurance is not currently accepted. *

Yes

I have concerns that I would like to discuss regarding costs/insurance.

I am aware that services are provided during evening hours after 5pm. *

Yes