Fill out this form to request an appointment for yourself. We look forward to meeting you!

We are always grateful when clients find us! How did you hear about us?

Home Street Address *

Gender Identity

Sexual Orientation

Which type of therapy are you seeking? *

Only if you are requesting Couples Counseling, please explain the current relationship dynamic:

Monogomous

Polyamourous

Please select your primary reason for seeking therapy *

Select additional reasons for seeking therapy below ( please check all that apply)

Which quality is most important to you in a therapist?

Will you be using EAP benefits?

Will you be using insurance benefits? *

What Insurance Company do you have?

What is the name of the primary insured person for this plan?

What is the birthday for the primary insured person for this plan?

What is the member ID for this insurance plan?

If there is a secondary insurance plan, please provide the plan name, primary insured and birthday, as well as the member ID.

Are you looking for In Person, Telehealth, or a Combination? *

Telehealth

In Person

Combination

No Preference

Are you open to Telehealth? *

Yes

Maybe

Preferred Method of Contact *

Any of the Above

Preferred Appointment Time

Preferred Appointment Days

Is there anything else that you would like to share with us?

Are you a Client Care Coordinator filling this out on behalf of a new client?

To submit this form, please first ensure that all required* fields are complete. By submitting this form, I understand that I may receive text communication to the phone number provided. I can opt-out of this communication at any time by responding STOP.