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

Name *
Name
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.
Which services are you seeking? *
Note: Hypnosis is not accepted through insurance. Please check all that apply.
If you plan on using insurance, please fill out our verify benefits form on the website to expedite placement with a therapist. If requesting pro-bono services, select pro-bono below.
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.