Request for Therapy

Request for Therapy

Joanne Bagshaw & Associates
Please complete the form below to request a therapy appointment. This form is HIPPA Compliant, and all information submitted is treated accordingly.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Please provide us with the following information so that we know which therapist is the best match for you:
What are you seeking therapy for at this time? *
Briefly describe the issue that you are seeking help for: *
Briefly describe the issue that you are seeking help for:
What are you seeking therapy for? Check all that apply.

Low DesirePainful SexSexual TraumaRelationship conflictPremarital CounselingInfidelity/ Affair recoveryInterfaith Couples CounselingCounseling for Interracial RelationshipsGeneral relationship and intimacy issuesMale sexual dysfunctionMismatched desireNon monogamous or polyamorous relationship counselingGender identityAdoptee counselingOther
Which state do you reside in (please note that some therapists are not available in all states listed): *
Do you prefer daytime or evening availability:
Which therapist are you interested in working with?
Status (for internal use)
Should be Empty:

Please provide us with the following information so that we know which therapist is the best match for you: