Counseling Consultation Request

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Please complete the form below to request a free 15-minute consultation. I do my best to respond to consultation requests within 2 business days. Emails may be sent to your junk folder so be sure to check there as well. Thanks!

Date *

YYYY

First and Last Name *

I am: *

a potential client.

the parent/guardian of a potential client.

Email Address *

Phone Number *

Briefly share why you are seeking counseling for yourself or your child at this time. *

Availability

I currently have openings on Weds and Thurs. Please indicate all of the times when you/your child are available to schedule ongoing sessions on those days.

Weds

Thurs

10:00am

11:15am

12:30pm

1:45pm

3:00pm

4:15pm

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Insurance *

The only insurance I am currently credentialed with is Lyra. I am an out-of-network provider with all other insurance panels. Non-Lyra clients who choose to work with me pay for services directly and submit superbills to their insurance for reimbursement (if their plan covers mental/behavioral health care).

I am open to going out-of-network for counseling.

I am accessing services through Lyra.

How did you find me? *

General Internet Search

Therapist Directory - Inclusive Therapists

Therapist Directory - Therapy Den

Word of Mouth

Other:

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