New Client Inquiry Form
Welcome! We are glad you're here! Please fill out this prospective client form to inquire about our services. Please note that completion of this form does not guarantee availability or that we may be a good fit for your needs. By completing this we are able to review your information and best determine if we can help you. We will follow up within 24-48 business hours upon receipt of your form. Thank you! We look forward to hearing from you.
Name
First Name
Last Name
Pronouns
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is it ok to text this phone number?
Please Select
Yes
No
Are you currently experiencing thoughts of suicide or thoughts of harming someone else? If you are, we encourage you to seek immediate support. This form is not monitored for emergencies. Please call or text 988 for crisis support, call 911, or go to your nearest emergency department if you are in immediate danger. You deserve support, and your safety matters.
Please Select
Yes
No
How did you hear about us?
Please Select
Psychology Today
Friend
Relative
Facebook
Instagram
Insurance
Primary Care Doctor
Google search
Other therapist referral
Are you seeking in person services, telehealth services, or both?
Do you have a provider preference? Please share their name if so.
Is there anything else you'd like to share/we should know?
Our pre-licensed clinicians bring valuable experience and specialized training, with the added support of ongoing supervision as they work toward full licensure. Would you be comfortable being scheduled with a pre-licensed or license-eligible provider?
Please Select
Yes
No
Submit
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