Name *

First Name

Last Name

Phone *

(###)

###

####

What is your preferred type of communication?

Phone call

Text

Email

Any

Your date of birth *

MM

DD

YYYY

Are you looking for virtual or in-person therapy? *

Virtual only

Virtual preferred

In person only

In person preferred

Any format

How quickly are you looking to start therapy? *

My need feels pretty urgent and I would like to get started in the next week or two.

Would like to start as soon as possible but can wait a few weeks if needed

I am not in a huge hurry and can wait a few weeks to a few months if needed.

If I don't have any immediate openings that match your schedule and other needs, are you interested in being placed on a waitlist?

Yes

No

Maybe