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Name *

First Name

Last Name

Phone *

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###

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Text Preference

Preference to receive text message response

Text welcome

Please do not text

Time structure you are interested in: *

Weekly, bi-weekly, monthly, or intensive options

I'm looking for a therapist to work with consistently

I'm looking for intensive short term (one day or week) therapy

I'm not sure

Interested in focus:

Choose any that apply to you

Spiritual Healing

Personality, Patterns, and Strengths Exploration

LGBTQIA+ Life

Other: please give context below

Office Interest:

In Person

Online

Walk and Talk

Mix of options

I understand that you will not bill insurance *

I Understand

I Understand That This Form Does Not Guarantee An Appointment Nor Is It The Start Of A Therapeutic Relationship. : *

I understand

I Understand That I Am Responsible For My Mental Health And Will Seek Appropriate Support While Waiting For A Response: *

I Understand

Acknowledgment: *

If in crisis, please contact 988

I am not in Crisis