Appointment Request for FREE CONSULTATION
Thank you for your interest in working with Tranquility Teletherapy PLLC! Please complete the form below so that we can match you with a therapist. We are looking forward to working with you!

Please note: We currently only offer teletherapy services to clients located in North Carolina or Texas.
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Name *
Date of Birth *
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Email *
Phone Number *
State of Residence *
Age of Client
Which therapy service(s) are you interested in?
Tell us briefly why you are seeking therapy services (ex. anxiety, depression, etc.).
Which therapist(s) are you interested in working with? If you choose multiple, our administrative team will explore your schedule and needs further to help you find the best fit.
Do you wish to use insurance to cover your sessions? If so, which insurance company provides your coverage? (Check all that apply.) *
Required
What days of the week will work best for your appointments? (Check all that apply.)
What time of day will work best for appointments? (Check all that apply.)
How did you hear about us?
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