Please fill out this form to assist us in contacting you at your convenience. 

Legal Name
Legal Name
If you are using insurance, use the name listed on your insurance card for verification reasons
he/him/his, she/her/hers, they/them/theirs, etc.
Phone Number *
Phone Number
Preferred form of contact *
Please let us know how you'd like to be contacted.
Best day(s) to contact you *
Please let us know which day(s) are best to receive contact. Selecting dates that align with your availability for sessions will help us determine a therapist that best fits your schedule.
Best time(s) to contact you *
Please give us a time span that works best on your preferred day(s). Selecting times that align with your availability for sessions will help us determine a therapist that best fits your schedule.
Best day(s) of availability for sessions
To be placed with a therapist right away, please fill this field out based on your current and/or expected availability
Best time(s) of availability for sessions
To be placed with a therapist right away, please fill this field out based on your current and/or expected availability
Which services are you seeking? Please check all that apply *
*Hypnosis is not accepted through insurance and a payment plan may be discussed. **Sliding scale services may be subject to a minimum rate per clinician. ***Pro-Bono services require an initial screening call which will be scheduled with you to determine appropriate placement.
Will you be using insurance for sessions? *
If you plan on using insurance, please fill out our verify benefits form on the website to expedite placement with a therapist.
Please clarify any information you feel is necessary to clarify for us and to determine which therapist is the best fit for you. This may include the purpose of your request or specifics on the best day and time to contact you.