Request A Therapy appointment
Hello, I look forward to partnering with you on your journey. Please fill out the form and I will get back to you with my availability to serve.
Please note: I currently do not take insurance but if you have a plan that reimburses you for therapy, you would be responsible to pay upfront and then we can provide a superbill for you to submit to your insurance. (Sliding scale available)
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Name *
Email *
Phone number *
Age(s) *
County of Residence (I can only see residents in CA)
 *
Best day(s) for weekly therapy sessions - select all that apply *
Required
Best time(s) for weekly therapy sessions - (45 min sessions) *
Preferred Location(s) - select all that apply *
Required
Please share the nature of the main problem you are seeking counseling for (e.g. anxiety, porn addiction...): *
How serious does this problem feel to you? Please rate 1-5. *
Not Serious
Extremely Serious
How did you hear about me? *
Comments
My current rate is $115 per session is this accessible to you? (I also provide a sliding scale)
 *
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