Appointment Request

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Appointment Request

We love getting to know new people!

This form is not for individuals currently experiencing a crisis. If you are experiencing a crisis, please call 911, visit the emergency department of a hospital in your area, or call/text the Suicide and Crisis Hotline at 988.

There is currently limited availability for in-person appointments in the Dallas-Ft. Worth area.

There is currently no availability for in-person appointments in Virginia or Colorado.

Telehealth appointments are available for clients in Texas, Virginia, and Colorado.

First Name *

Last Name *

Name you use

Date of Birth *

YYYY

Phone Number *

Street Address *

City *

State *

Zip Code

Email *

Which services are you interested in?
(You may choose more than 1) *

Traditional Counseling

EMDR

Psychedelic Integration

Non-Psychedelic, Non-Ordinary States of Consciousness

Therapy for Ketamine Patients

I prefer to discuss directly with my counselor

Required

Have you been seen at our practice previously? *

Yes

Which state are you in?

Unfortunately, we only offer services in Texas, Colorado, and Virginia.

To be notified when we offer services in your state, click here for our wait list.

Texas

Colorado

Virginia

I maintain residences in more than one state

Will you be using insurance?

Please note that insurance acceptance varies by state.

Yes

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