Request for Counseling Appointment
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Who is seeking counseling?
*
Myself
My partner and I
My teenager
Other
If other, please describe:
Did someone refer you? If so, could you please list your referral source.
Briefly describe what is bringing you to counseling:
*
I am seeking:
Online therapy
In person therapy
What availability do you have to meet with me? Please identify all available windows as my availability is limited.
*
Monday afternoon/evening (1-6)
Tuesday morning (8-12)
Tuesday afternoon/evening (1-6)
Wednesday morning (8-12)
Wednesday afternoon/evening (1-6)
Thursday morning (8-12)
Thursday afternoon/evening (1-6)
Other
If you chose other, please describe what availability you have.
If we have matching availability, what would you like your next steps to be?
*
Please Select
Schedule a consult call to ask followup questions
Fill out intake paperwork to schedule a session
Other
If other, please list here.
I do not take insurance, and my rates are $120/hour. In checking this box, you acknowledge your consent to self-pay for therapy services.
*
I understand the self-pay policy
By signing your name below and submitting this form, you consent to being contacted regarding counseling services.
Continue
Continue
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