Contact and Intake Form
Hello, please fill out this form to request an appointment. This form goes directly to our HIPAA compliant, secure mailbox. You will be contacted with instructions for your patient portal to fill out paperwork and have your appointment confirmed.
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Email *
Name *
Email Address *
Phone Number
Date of Birth (Required for TherapyPortal) *
Do you have insurance? *
If so, is it through an employer or through the state? *
My insurance is through: *
Reason for Therapy (Just a sentence or 2)
Availability- Check all that apply (All Sessions are Online)
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