Request an Appointment

First and Last Name *

Email Address *

Phone Number *

Preferred Contact Method *

Email

Phone (Text)

Which service are you seeking? *

Individual Therapy

Couples Therapy

State of Residence *

Kentucky

Ohio

Indiana

Preferred Location of Therapy *

In Person

Virtual

*

I am aware that seeking therapy with Dr. Allison Smith will be out of pocket as no insurances are accepted

I acknowledge that I am (or the person I am reaching out on behalf of is) 18 years of age or older

Required

Reason for Therapy *