New Client Request

We’re here to help you connect with the right therapist. This form gives us the information we need to make the best match for your needs and preferences.

After you submit, you’ll get a confirmation email and one of our stellar clinincians will be in contact shortly to arrange a time to connect.

[Please note that if you’re in crisis or need immediate support, please contact Crisis Connections 24-Hr Crisis Line: 866-427-4747 or your local emergency services. This form is not monitored in real time.]
Your Contact Information
Name*

FirstLast
Pronouns
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Do we have your consent to leave a voicemail?

YesNo
Are you currently residing in Washington State?*

YesNo
To comply with licensing regulations, we can only offer services to clients currently located in Washington State.
What You're Looking For
Tell us a bit more about what you're looking for support with:*
Briefly share the concerns, goals, or topics you'd like to work on. This helps us match you with the right therapist.
What type of therapy are you looking for? (Check all that apply)*

Individual TherapyRelational TherapySex TherapyArt TherapyDrama Therapy
Participant 2 Name

First NameLast Name
Participant 2 Email
example@example.com
Participant 3 Name

First NameLast Name
Participant 3 Email
example@example.com
Therapist Preferences

Tell us if you have a specific clinician in mind, or share any qualities or specialties that are important to you. This helps us make the best possible match.
Therapist Preference (select any clinicians you are interested in working with)

Kate Stewart ($250)Clinical Interns ($80)Jennifer AndersonAndi ErpenbachJulie FortneyQuinn BrenfleckRobin EdwardsBrantly IracleanosAnnabelle WagarDylan HigginbothamAubrey Rachel VioletI'm not sure, please help me choose.
Availability varies throughout the year, and we will match you with the best-fit intern based on your needs, schedule, and availability.
Annabelle’s in-person days:
Seattle: Mondays, Tuesdays, & Saturdays (Telehealth available other days)
No problem! We’ll review your information and connect you with a clinician who fits your needs and preferences.
Jennifer is only available via telehealth.
Brantly’s in-person days:
Seattle: Thursdays & Fridays (Telehealth available other days)
Quinn's in-person days:
Seattle: Mondays & Fridays (Telehealth available other days)
Robin’s in-person days:
Seattle: Tuesdays & Thursdays (Telehealth available other days)
Julie’s in-person days:
Seattle: Wednesdays (Telehealth available other days)
Dylan's in-person days:
Seattle: Mondays, Wednesdays, & Sundays (Telehealth available other days)
Andi’s in-person days:

Bellingham: Thursdays & Fridays (Telehealth available other days)
Aubrey's in-person days:
Seattle: Mondays (Telehealth available other days)
Additional Preferences
Optional: If there are other preferences that would help us match you well, please let us know.
Appointment Preferences

Share your appointment preferences. We’ll work to honor them, though in-person options depend on each clinician’s designated office days.
How would you like to meet?*

In PersonTelehealthI'm ok with either!
If you'd like to meet in person, which location?

SeattleBellingham
General Availability:
Accessibility Needs / Accommodation Requests:
Final Details
How did you hear about Modern Therapy Seattle?
Consent & Communication Acknowledgement*

I consent to be contacted using the information I provided.
Should be Empty:

Your Contact Information

What You're Looking For

Therapist Preferences

Appointment Preferences

Final Details