Name *

First Name

Last Name

Phone *

By providing your phone number you are consenting to being contacted via phone.

(###)

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Do we have permission to leave a voice message?

Yes

No

Are you a new client? *

Yes

No

Which do you prefer? *

*Please note that not all insurance plans are covering telehealth at this time

Telehealth/Video Sessions

In-Person

No Preference

What issues/concerns are you wanting to address?

Anxiety/Panic

Depression

Family Dynamics

Personality Disorder

Trauma-related

Relationships

Disordered Eating

Body Image

Stress

Substance Use

Anger/Aggression

Women's Issues

Other (please explain in the comments/questions section below.)

Preferences you would like considered *

Select all that apply

A provider who identifies as female

A provider who identifies as male

A provider who identifies as Black

A provider who identifies as Hispanic or is Spanish-speaking

A provider who identifies as POC

Day time availability

Evening availability

Weekend availability

A provider who identifies as LGBTQ+ or LGBTQ+ affirming

A provider I was specifically referred to (please indicate which provider in the comments section)

I have no specific preferences and am open to working with any provider