Let's Get Started

Please complete this form in its entirety if you are ready to become a new client.
Your information is securely sent to our intake department's email.
Once received, someone from our intake team will be in touch with you.

Date of Birth required

Address (please include city, state and zip)

What services are you looking for? Required

Individual counseling

Couples therapy

Wellness coaching

Is there a particular event that brings you to counseling at this time?

What time of day works best for you to schedule your sessions? Required

morning (9am-11am)

afternoon (12pm-4pm)

evening (5pm-8pm)

weekends only

Please add additional specifics about your availbility here: (i.e. available Mon mornings and Wed afternoons)

Please upload your insurace card so we can provide an estimate of your copay

Upload File

Upload supported file (Max 15MB)

Please upload your ID or driver's license

Upload File

Upload supported file (Max 15MB)

Do you have a preference in the gender of your therapist? Required

Female

Male

No preference

Other

Are you comfortable with seeing a clinician in training for services? (Services are offered at a discounted self-pay rate) Required

Yes

No

Maybe, but I would like more information

Are you comfortable with a graduate student shadowing your first session? Required

Yes

No

Maybe, but I would like more information

Is there anything else you would like us to know?

Thanks for submitting!