We’re Glad You’re Here

Your First and Last Name *

First Name

Last Name

Client’s First and Last Name *

First Name

Last Name

Phone *

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Client’s Date of Birth *

MM

DD

YYYY

Please indicate what your availability is for meeting with a counselor. Appointments after 4PM are less frequent, so we'd like to especially know if you have availability during the daytime.

Daytime

Evenings

Are you willing to pay out-of-pocket ($75 to $120) for sooner availability in the case of insurance providers' waiting lists?

Yes

No

Are you willing to see an intern for $0 to $45?

Yes

No

Are you willing to meet via telehealth?

Yes

No

I acknowledge that submitting this message does not constitute the beginning of a counselor/client relationship. *

Yes