CSIC Waitlist

Appointment Waitlist

Please complete this form to join our waitlist. We will reach out via email as soon as your preferred clinician has availability to see new clients.
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
What is the best way to contact you about appointment availability?*

Text messageEmailPhone call
Are you interested in individual sessions, or couples(+) sessions?*

Individual therapyCouples therapy
Please select any/all clinician(s) you would be interested in seeing for individual therapy. More info here: www.clesexandintimacycounseling.com/clinicians*

First available in personFirst available telehealthMeg BauhofJillian DeCarloRachel DrotarAsh Eging (telehealth only)Brielle GiominiJamie GreenwolfHannah HarrisMiguel Hernandez (telehealth only)Brenna KeggJessie LeuAbigail LindenmeierSam MillerKat RodgersJa'Mera RossKate ShaverCamryn SmithSara TiliskyAnnmarie Watson (telehealth only)Carmen Williams (telehealth only)Elliot Williams (telehealth only)
Please select any/all clinician(s) you would be interested in seeing for couples therapy. More info here: www.clesexandintimacycounseling.com/clinicians*

First available in personFirst available telehealthJillian DeCarloRachel DrotarAsh Eging (telehealth only)Brielle GiominiHannah HarrisBrenna KeggJessie LeuAbigail LindenmeierKat RodgersJa'Mera RossKate ShaverCamryn SmithAnnmarie Watson (telehealth only)Carmen Willams (telehealth only)Elliot Williams (telehealth only)
Partner(s) Name
First & Last
Have you had an appointment with a clinician at CSIC in the past?

YesNo
Have you or your partner(s) had an appointment with a clinician at CSIC in the past?

YesNo
When are you generally available for appointments? (select all that apply)

Weekdays - daytimeWeekdays - eveningsWeekends
Were you referred to CSIC? If so, by who?
Anything else you'd like us to know:
Should be Empty:

Appointment Waitlist