Name

First Name

Last Name

Email

Phone

(###)

###

####

How did you hear about us?

Personal/Professional Recommendation

Psychology Today

Insurance In-network Provider List

Google Search

Social Media

If you found us through a recommendation, please share who recommended us.

I.e. Friend/Family Member, Dr. John Doe, etc.

What is your availability for appointments?

Are you planning to use insurance?

Yes

No, I'll pay out of pocket

If yes, which insurance company?

Please note: We don't take Medicare or Medicaid

Provide a brief explanation of why you're seeking support:

Let’s get started.

To begin the process of setting up an appointment, simply fill out the form below. We’ll get in touch with you promptly to arrange a time that works best for you.