Please tell us about you!
This form is to express interest in working with Cristi Anne Wilson, LCSW.

Focused Healing Intensives are customized immediate support for individuals. Intensives are 3+hours per session, which can be a very rich experience effecting positive progress in a short amount of time. 
Please note that intensives are outside of insurance coverage. For more on intensives, click here.
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Potential Client Name *
Age of Potential Client *
Parents/Caregivers Names (if potential client is a minor)
Email Address *
Phone Number *
Concerns- Briefly share what is prompting you to seek therapy at this time (such as: Trauma History, Depression, Anxiety, Recent Traumatic Event, etc.) *
What type of therapy experience are you looking for? *
Heart Space is in-network with those listed below. *Please be aware that it is very rare for insurance to cover Focused Healing Intensives.
*You may add your insurance name in "other", however Heart Space does not have contracts with other insurances
*Select as many as are true for you (including secondary plans)

Who referred you to Heart Space? *
Where would you prefer to work with Cristi?
(select all that apply)
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