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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? *

Insurance card Images

If you are able, uploading an image of the front and back of your insurance card will help guide us to better understanding of your provider and what your benefits might be

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Insurance Card Back *

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