Appointment Request

  • Thank you for your interest in counseling. I currently have limited openings for new appointments.
  • If you'd like to be considered in the event that an appointment becomes available within the next 4 weeks, you are welcome to complete the form below. If I don’t have an opening that fits your availability, I may not follow up — but you are always welcome to check back in the future.
  • Your responses are confidential.

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Your Name: *
Email: *
Phone:
How did you hear about Whole Heart Counseling?
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Who is this appointment for? *
*If for a child, dependent or loved one please add their name here:

What days and times are you generally available for appointments?

 *
If an appointment becomes available in the next 4 weeks that matches your availability, I will reach out.

*Please note: I do not keep a formal waitlist, so if I don’t have an opening that fits, I may not follow up. You are always welcome to check back in the future.
Would you like to use insurance if possible? If yes, please refer to the Insurance Information page on the website to see if I am in-network with your provider. *
What is your insurance provider?
What brings you to therapy at this time? *
Anything else you’d like me to know?
Consent Acknowledgment  *
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This form was created inside of Whole Heart Art Therapy & Creative Counseling, LLC.