Schedule an Appointment for Counseling

Thank you for your interest in our counseling services. Due to the significant amount of demand for our services, at this time we are temporarily unable to accept any new clients. Please sign up for our newsletter for information on groups and community workshops we are offering until we can accept new individual clients.

Name*
First Last
Preferred name
Gender
Preferred pronouns
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Cell Phone*
Home Phone
Best time to reach you
Date of birth*
MM
DD
YYYY
Health insurance plan name (type in N/A if self pay)*
Health insurance plan ID Number (type in N/A if self pay)*
Copay information
Desired service
What is bringing you to therapy?*

Schedule an Appointment for Counseling

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