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Therapy Interest Form
Thank you for expressing interest in scheduling an appointment with Akoma Counseling Concepts. Please complete the information below to be scheduled with an appointment with a Licensed Clinician and Graduate Student Intern on our clinical team. Please allow at least 72 hours for a member of our team to contact you.
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Email
*
Your email
Name:
*
Your answer
Email address
*
Your answer
Phone
*
Your answer
State of Residence (We only see clients in Maryland and DC)
*
Maryland
Washington, DC
How soon are you looking to schedule your appointment?
MM
/
DD
/
YYYY
The issue(s) I am seeking to treat in therapy (in 4 sentences or less):
*
Your answer
Have you been to individual therapy before?
Yes
No
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