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Legal Name *

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Preferred Name (if Different) *

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Best Email *

Best Contact Phone Number *

Best Form of Contact *

Date of Birth: *

Who is your inquiry for? (child, self, etc.) *

If this is for your child, what is your child's name and date of birth (dob)? *

If this is for couples counseling, what is your partner's name and date of birth (dob)? *

What services are you inquiring about? *

Session Frequency *

Would you prefer in person or teletherapy sessions? *

A few key points of what you would like to focus on in session *

Any counselor preferences? Gender, age range, modality? *

General Availability for Scheduling Appts *

If you have health insurance you would like to use, please enter your insurance company below: *

If you will be not be using health insurance, do you need our low cost counseling options? *

If you need our low cost counseling options, how much can you afford per session? *

Any other information that you'd like to share? *

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