Request Services

To make a referral, request services, or to learn more about if our services are a good match for you, please complete the form below. We will do our best to get back to you within two business days to follow up or provide you with a match with one of our providers.

New Client Form

Name of client:

Client's gender identity and preferred pronouns (e.g., female, she/her; non-binary, they/them):

Client's age:

Who should we contact to set up services? If someone other than the client, please provide their name and relationship to the client.

Client

Other

Preferred method of contact for this person (email, phone call) and the best email address and/or phone number:

Preferred payment method for services (if using insurance, please list primary insurance and any secondary/supplemental insurance coverage):

Private Pay

Insurance

Preference of location for appointments (telehealth, in-person, or no preference):

Please provide a brief summary of the client's goals for therapy:

Please share any preferences regarding services, therapy approaches, providers, or preferred language(s) for scheduling and sessions:

How did you hear about us? (e.g., internet search, personal relationship, another provider):