Name

First Name

Last Name

Email

Phone

(###)

###

####

In which state do you currently reside?

What are you seeking therapy for at this time?

Do you have weekday daytime availability for sessions?

Yes

No

Do you plan on using insurance for sessions?

Yes

No

If planning to use insurance, who is your insurance provider?

You can leave blank if you don't know or are not planning to use insurance.

Session availability is between 8am-6pm EST Monday-Friday