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Please complete the form below

Name *

First Name

Last Name

Email *

Phone

(###)

###

####

Where are you located? *

What kind of support are you looking for? *

1-1 Therapy, just for me

Couples Therapy - weekly sessions

Couples Coaching - bimonthly sessions

Group Coaching for Couples - bimonthly sessions

Not sure yet

What brings you to seek support at this time? Is there something specific, such as a particular event? Be as detailed as you can. *

What are your goals for therapy or coaching? *

Have you seen a mental health professional before? *

YES

NO

Choose the option that best describes you: *

I’m ready for 1-1 support, with a lot of personal attention

I do well learning in groups and would be open to group therapy or coaching

I’m still figuring out what I need

Have you read through the rates and fees page and are you aware that we don’t accept insurance directly? (But we are happy to provide paperwork so you can submit for reimbursement) *

YES

NO

How did you find me? *

Referral, please let me know who to thank

Google Search

Online Publication

On a podcast

Facebook

Instagram

LinkedIn

Other

Name of person who referred you (if applicable)

Thank you so much for taking the time to share and for making space for your personal healing. I aim to be in touch within 2 business days and look forward to connecting with you more soon!

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Email Address *

First Name *