Your email (if you are comfortable with email correspondence, which is not secure): *
Your preferred phone number for me to contact you: *
Please briefly describe what you'd like my help with: *
If we could accomplish a miracle in our work together, what would you want that to be? *
For the sake of achieving that miracle, would you be willing to engage in daily homework between therapy sessions, such as monitoring thoughts, feelings and behaviors; practicing new behaviors; and engaging in written assignments? *
If you are comfortable with email correspondence, I will reach out to you initially by email. Otherwise, what sorts of times might be convenient for you to receive a call from me? *
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