Name *

First Name

Last Name

Phone

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I'm looking for help with...

Please check all that apply

Stress or Life Transitions

Depression or Overwhelming Emotions

Anxiety and/or Worrying Too Much

Panic, OCD, or a Specific Phobia

Trauma/PTSD

Dissociation

Sleep Problems (Insomnia and/or Nightmares)

Grief and Loss

Substance Use or Addiction

Disordered Eating and Body Image Concerns

Psychosis/Schizophrenia

Relationship Therapy

Psychological Testing or Evaluation Only

Waitlist Option

If no appointments are available within the next month, I would like to be added to your practice waitlist

Yes

No