We’re Glad You’re Here

Your First and Last Name *

First Name

Last Name

Client’s First and Last Name *

First Name

Last Name

Phone *

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Client’s Date of Birth *

MM

DD

YYYY

Please indicate what your availability is for meeting with a counselor. Appointments after 4PM are less frequent, so we'd like to especially know if you have availability during the daytime.

Daytime

Evenings

Is it OK if we reach out by text if you cannot be reached by email?

Yes

No

Are you willing to pay out-of-pocket ($75 to $120) for sooner availability in the case of insurance providers' waiting lists?

Yes

No

Are you willing to see an intern for $0 to $45?

Yes

No

Are you willing to meet via telehealth?

Yes

No

I acknowledge that submitting this message does not constitute the beginning of a counselor/client relationship. *

Yes