Preferred method of contact? (i.e. phone call, text, email) *
Payment Preference? *
If insurance, what insurance provider?
If insurance, are you willing to use your out-of-network benefits to insure best therapist?
Are you interested in seeing one of our graduate intern counselors for a significantly reduced fee? Intern counselors are supervised weekly by seasoned therapists and provide excellent counseling at a reduced rate.
Who referred you?
May we contact the person who referred you to thank them?
Name of person who referred you:
Please describe the primary reasons you are seeking counseling support for yourself or someone else:
Is there anything else you think would be important for us to know?
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