To schedule an individual, children, couples, marriage or family therapy appointment or to obtain additional information about any of these counseling services, please email us this information below or give us a call with this information to streamline the services efficiently/quickly.
Patient Name:____________________________
Type of therapy:___________________________
Specific therapist requested:__________________________________________
Male or Female therapist requested:__________________________________
Insurance Provider:____________________________________________
Date and time requested for appointment:___________________________
We are committed to your privacy. Do not include confidential or private information regarding your health condition in this form or any other form found on this website. This form is for general questions or messages to the practitioner.