Request Appointment
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Email *
Name *
Pronouns
Phone
Type of Therapy Requested *
Required
Session Format Preference
Weekday Appointment Availability
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday & Weekend Appointment Availability
Morning
Afternoon
Friday
Saturday
Sunday
Do you have private insurance coverage?
If yes, which professional providers are covered under your insurance? Please note we do NOT have psychologists at our clinic! Check your insurance for the the registration title e.g. psychotherapist, not descriptive terms like psychotherapy.
Would you prefer a therapist with (check all that apply):
Is there a therapist you're interested in working with? (if available/matches needs). Please fill in their name if so:
A copy of your responses will be emailed to the address you provided.
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