Book Appointment

First and Last Name

Your email

Your phone number

Preferred contact method
Phone CallEmailText MessageOther (explain below)

Concerns You Want To Address In Therapy (check all that apply):
AnxietyDepressionPast TraumaOngoing Abuse/NeglectCriminal HistoryInterpersonal Conflicts/IssuesFamily ConflictSubstance Abuse/AddictionHallucinations/DistortionsSexual IssuesWork Stress/IssuesAcademic Stress/IssuesLGBTQ+ Identity IssuesRacial IssuesExistential ConcernsMood/Emotion ManagementDiet/Exercise/Weight ConcernsSleep HabitsMental Health due to a Medical IssueSuicidal Ideation/AttemptsHomicidal Ideation/AttemptsIssues with Memory/BlackoutsOther

Which General Therapeutic Approach Are You Looking For?
CBT – A therapist who provides coping skills and problem-solving techniques to help me navigate my concerns.Psychodynamic – A therapist who engages in a conversation with me to explore and process the deep roots of the problems I face. The conversation itself will help me find the insight to create change in my life.Integrative – A therapist who does both CBT and Psychodynamic approaches

Are you currently engaged in a different treatment program? (Rehabilitation, inpatient, outpatient, or
psychiatric medication management?) Please provide a few details.

Are there any identity preferences for your preferred therapist? (Racial, Sex/Gender, Sexual
Orientation, etc.)

Will you be using insurance to pay for therapy, or will you be paying out of pocket?
Insurance (please provide the name of your insurance provider)Out of Pocket

Insurance provider name:

Is there anything else you want us to know beforehand?

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