New Client Contact 
Fill out this form if you are interested in being a new client or want to set up a consultation. 
It is our goal to respond in 24-48 business hours. 

****Filling out this form does not establish the client/therapist relationship, and should solely be used for therapy inquiries. If you need immediate assistance, please call or text 988, 911 or proceed to your local ER.**** 
Legal First Name *
Legal Last Name *
Name You Go By (if different than above)
Gender  *
Pronouns *
State you are located in? *
Date of Birth *
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Email *
Phone Number *
Preferred method of follow up contact to this form: *
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What are you wanting to work on in therapy? *
How do you prefer to meet for therapy sessions?
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Anything else you want us to know in regards to your inquiry?
What insurance do you have (if any)? 
Would you like to do a free 15 minute consultation before getting started? 
How did you find us?
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