Name *

First Name

Last Name

Phone *

(###)

###

####

Do you consent for us to contact you through phone and email, and leave a voice message? *

Yes

I understand that all sessions are conducted virtually only over video call or phone calls based on the patient's preference. *

Yes

What teletherapy method are you interested in? *

Video Sessions

Phone Sessions

What services are you interested in? *

Individual Psychotherapy

Screener Tests

Marriage & Couples Therapy

Family Therapy

I have checked the session rates and have sufficient insurance coverage or personal funds for potential future sessions. *

Yes

I am planning to begin psychotherapy sessions potentially within the next 30 days or less. *

Yes