Therapy Services Consultation Request
Please fill out this form to request a consultation for therapy services. You will be contacted by our admin within 24-48 hours to discuss scheduling a free 15-minute consultation with a therapist. 
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Full Name *
Email Address *
Phone Number *
Preferred Method of Contact *
Date of Birth *
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Reason for seeking therapy services? *
What type of therapy are you interested in? *
Required
If seeking couples therapy, please provide the first/last name, DOB, phone number, and email of your partner. 
Please check all, if any, other modes of therapy you are/would be interested in.
        *If you are only interested in more traditional/talk therapy, select none.
        **Please note: All of our therapy is person centered, sex positive and takes the format of whatever you are most comfortable with.
 *
Required
In reference to the previous question, please specify if you would like these services as your main source/type of therapy, as an add on, or both.
         *i.e. You could choose both Holistic Therapy and Art therapy and have Holistic Therapy as your main source and art therapy as an add on.
 *
Required
Which counselor do you prefer to receive care from? Please see website for more details on specialties and interests. *
If your preferred counselor isn't available, are you comfortable seeing a different counselor? *
How did you hear about our services? *
What days of the week are you generally available for a consultation? *
Required
What form of payment do you plan to use? *
What is your preferred time of day for a consultation? *
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