Name * First Name Last Name Pronouns (Optional) Email * Phone Number (Optional) (###) ### #### What type of therapy are you interested in? * Individial therapy for minor Individual therapy for adult Relationship counseling Family Therapy Where to meet for sessions? * Online/virtual therapy In Person No Preference What are you hoping to address in therapy? * Therapist Preference (Optional) How do you plan on paying for therapy? * In Network Insurance Out of Network Insurance Out of pocket/cash pay HSA/FSA How did you hear about us? * Thank you!
