Wait List Form

WAIT LIST FORM
Thank you for your interest in my practice. Currently, I am on a waitlist and will not be accepting new clients until October 1, 2026 at the earliest. If you would like to be added to the waitlist please complete this form. If there are clients, that graduate from my practice before October, I will reach out to propsective clients in the order of completion of this form.
CONTACT INFORMATION
Legal Name

First NameMiddle NameLast Name
Preferred Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Location

CityStateTime Zone
GENDER PRONOUNS (click all that apply)

Other (specify below)
Please provide any other pronouns not listed above
THERAPUTIC NEEDS
What type of services are you seeking?
If seekinging services for a couple please provide your partners name and how long you have been together.
What prompted you to seek counseling or coaching at this time? What are the top 2–3 concerns you would like help with?
SCHEDULING
How soon are you hoping to be seen?
In Person (North Ridgeville office) or Online (via Zoom) Sessions
Which days work bet for you?
Which timeframes work best for you?
If you have an immediate need, would you like me to offer a possible referral? If yes any specific you are seeking?
Should be Empty:

WAIT LIST FORM