Request for Mental Health Services 
Contact us to schedule a free 15-minute phone consultation. I'll be sure to follow-up within 24-48 hours. Inquiries received after business hours will be responded to on the next business day.

*We are no longer accepting new clients for minors, any new requests will be pre-screened and added to the waitlist for future openings.
First Name *
Last Name *
Email *
Phone number *
Date of Birth: *
State of Residence *
Briefly explain what is bringing you to therapy at this time? *
How do you intend to pay for services? *
How do you preferred to be contacted? *
Required
Are you interested in Virtual or In-person Therapy? *
Is this request for a minor? (under the age of 18) *
If this request is for a minor, please list the Name & Contact Info of the adult who is responsible for the child. (ex. Jason Smith, Legal Guardian) If not, please write N/A *
When is the best time to contact you for an phone consultation? (We typically conduct consults, weekdays between 11 am - 3 pm EST, Tuesdays - Fridays).  *
How did you hear about us? *
Required
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