Individual Consultation

1
How did you first come in contact with us?* This field is required.
Google
Instagram
Referral
Other
2
Which of the following best describes your current relationship status?* This field is required.Please tell us a little bit about yourself, so that we can better understand your situation
Single
Dating / Long Term Relationship / Engaged
Married
3
Can you tell us about yourself and what's making you seek guidance now?* This field is required.Please be as detailed and specific as possible
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4
Describe any sexual concerns you may have.* This field is required.Please be as detailed and specific as possible
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5
What are you looking to achieve as we work together?* This field is required.Again, please be as detailed and specific as possible. What’s your vision or dream here? What would you define “success” as?
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6
Which clinician do you prefer to work with?* This field is required.We'll do our best to schedule you with your preferred clinician, and we can also talk about which provider might best meet your needs.
Banesha Wood
Kandice Ewing
Nakia Roberson
No Preference
7
What time of day works best for you?* This field is required.
Mornings
Afternoons
Evenings
Weekends
8
How ready are you to start therapy? Rate yourself from 2 (not really) to 10 (I'm ready to start yesterday!)* This field is required.
2
4
6
8
10
9
Will you be using...* This field is required.We are currently in-network with the listed insurance
Self Pay
Aetna
Cigna
Optum
United Health Care
10
“By submitting this form, I understand that this does not create a therapeutic relationship and that a consultation is for informational purposes only.”* This field is required.List the name of your insurance company, ID number, DOB and insurance company phone number.
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11
Not Finished Yet... Last (And Most Important) Step! Please Confirm Your Contact Information Below, And Then Select A Time For A Consultation Call On Our Calendar* This field is required.STEP 1: Submit contact information below STEP 2: On the next page, PICK OUT A TIME that works with your schedule. STEP 3: We'll contact you almost immediately to confirm your time.
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