Appointment Request Form
Let us know how we can help you!
Full name of person requesting services
First Name
Last Name
Full name of person to attend therapy (if not same as above)
First Name
Last Name
Relationship to person attending therapy
Parent, spouse, etc.
Type of Therapy Requested
Individual Adult Therapy
Couples Therapy
Child Therapy (Ages 6 and up)
Youth Therapy (12+)
Family Therapy
Please tell us more about the reason you are seeking therapy, what type of therapy you are hoping to receive, and anything else you would like us to know in order to place you with a therapist.
Insurance plan for therapy coverage (if applicable)
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
How would you prefer us to contact you?
Please Select
Phone
Email
Submit
Should be Empty: