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Interest Form for New Clients

Please use the form below to let us know what you are looking for and to make scheduling faster and easier. All fields need to be completed before submitting.   

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1. Fill out the form (make sure to click "submit" at the end)

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2. After you complete this form, you'll be prompted to schedule a call with us to go over availability and book your first appointment. That helps us avoid phone tag and make the process smoother. 

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If this is an urgent, life-threatening emergency, call 988, 911, go to your nearest hospital, or contact your local crisis line.

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DISCLAIMER: Please only provide your basic contact information. We will discuss your needs in more detail over the phone. Completing this form does not establish a therapeutic relationship, nor does it guarantee confidentiality, availability, or an appointment.

Age range of prospective client (s) Required
Contacting us about? Choose 1 or More: Required
Service(s) you are interested in, check all that may apply: Required
Preferred location(s) for therapy appointments - check all that you are open to: Required
Days of the week you are available for appointments Required
Times you are available for appointments: NOTE - Appointments after 2:00pm are in high demand and are rarely available. Please let us know all of your availability so that we can work to find a time that fits your schedule!** Required
Preferred Provider Required
Form of Payment: ***Note the insurances listed are the only ones we accept and this can vary based on the individual provider and meeting medical diagnosis criteria.** Required
Upload File
File Type: .bmp,.gif,.heic,.heif,.jfi,.jfif,.jpe,.jpeg,.jpg,.png,.tif,.tiff,.webp (25 MB Max)
Upload File
File Type: .bmp,.gif,.heic,.heif,.jfi,.jfif,.jpe,.jpeg,.jpg,.png,.tif,.tiff,.webp (25 MB Max)

The next step is to choose a time for us to call you.

 

Upon clicking 'Submit', you'll be directed to a page where you can choose a convenient time for our call. This helps us avoid phone tag!

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During this brief administrative call with our intake coordinator, we will go over clinicians availability and get you scheduled for your first session. 

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