Start Your Journey

Welcome!

I’m glad you’re considering therapy as a step toward healing and growth. Please note that my services are self-pay, and I am an out-of-network provider. This means that you will be responsible for the full fee at the time of service. However, I can provide you with a Superbill to submit to your insurance for potential reimbursement. If your insurance plan includes out-of-network benefits, you may be reimbursed directly for a portion of the fee, depending on your plan’s coverage.

To ensure I place you in the right therapeutic service, please fill out the form below. Once I’ve received your request, I will personally review it and reach out to schedule your appointment.

Thank you for taking this step. I look forward to connecting with you soon!

Patient Name

First Name

Last Name

Parent or Guardian Name (if applicable)

First Name

Last Name

Client's DOB

MM

DD

YYYY

Client or Parent Email

Phone Number for Follow-up

What Brings You to Therapy?

Please tell me what you're needing from therapy, the severity of your symptoms and goals.

Desired Service

Individual Therapy

Couples Therapy

Family Therapy

Type of Therapy/ Services Received Previously

Availability?

Days and times you are generally available to meet with me.

Anything You Would Like for Me to Know?

Location of Services

In-Person, at our Center

Telehealth

Follow-Up Information:

I personally review all inquiries and aim to respond within 48 hours.

Thank you for your patience.

Privacy Statement:

Your privacy is important to me. All information shared on this form is confidential and will only be used to coordinate your care.