Consultation Request
Please complete this secure form and after submission you will be redirected to book your free consultation call through our internal system.
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Last Name  *
First Name *
Email Address *
Phone Number *
Age  *
Where are you located?  *
Which therapist are you looking to have a consultation with? If you are not sure who you would like to book with, please book your call with Mary Tate to help match you with the best fit.  *
Please share any details that may be helpful for the therapist to know prior to your call. (what you hope to work on, current symptoms, questions you may have) 
Payment Preference  *
Will you or a 3rd party be responsible for financial responsibility? This gives us a heads up on how to review any financial questions that you may have during your call! 
How did you find us?  *
Do you have a preference of how we communicate with you prior to your consultation?  *
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