Getting Started
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Date Of Birth
*
-
Month
-
Day
Year
Date
Gender Identity
Please Select
Male
Female
Nonbinary
Other
Preferred Therapist
*
Michele Waldron
Susan Ott
Terry Burch
No Preference
What Service Or Services Are You Looking For?
*
Individual Therapy
Ongoing Couples Therapy
3-6 hour couples intensive weekend/evening virtual/in person Bedford, MA (virtual session is $250 per hour, in-person session is $275 per hour)
Men's Compulsive Behavior Groups
Parent Consultation
18-week Pelvic Pain Group
Betrayed Partner Support Group
ESense Health Training
How did you hear about us?
*
AASECT Website
Psychology Today Website
Social Media
Therapist
ESense Health
Gottman Directory
Medical Provider
Other
If referred by Medical Provider, please list name / practice
How can we help you? Please be specific so we can match you with the best clinician
*
I understand that we do not accept or bill insurance. Please see the PAYMENT PAGE on our website for rates and questions to ask your insurance about out of network coverage.
*
Please Select
Yes
No
Preferred Time For Sessions
*
Please Verify That You Are Human
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