Connect

Name *

First Name

Last Name

Phone Number *

(###)

###

####

Text message response is welcome: *

Clinician will follow up with text if email response does not go through.

Yes

No

Interested in focusing on:

LGBTQIA+ Life

Spiritual Healing

Personality, Patterns, and Strengths Exploration

Other: please give context below

Office Interest: *

Availability for online sessions for individuals in Virginia. Availability for walking sessions and in person office in Roanoke, VA area.

Telehealth Online

Walking and Nature Option

In Person Office Sessions

One Day Online Intensive

A mix of options

Insurance

All insurance providers are considered out of network

I understand that you will not bill insurance

I want a diagnosis to request insurance reimbursment that I will submit on my own

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

Acknowledgment

I Understand

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

Acknowledgment

I Understand

Acknowledgment *

I am not in Crisis