Name *

First Name

Last Name

Phone *

(###)

###

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Who are you seeking therapy for? *

Me

My partner and myself

Someone in my care (i.e. child, family member, etc.)

Family member(s) and myself together

I am not seeking therapy

Which type of clinician are you open to seeing? *

*Sliding Scale rates available across all counselor levels

Senior Counselor (session fees range from $125-160)

Associate Counselor (session fees range from $110-150)

Graduate Level Intern (session fees range from $20-80)

Preferred Appointment Days *

Please check all that apply.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Preferred Appointment Times *

Please check all that apply.

Morning

Afternoon

Evening