Appointment Request Form
Fill out this form to request an appointment for yourself. We look forward to meeting you!
First Name*
Last Name*
Email*
Phone*
Age*
Enter Your Date of Birth in this format: YYYY-MM-DD*
Gender Identity*
Female
Male
Trans Female
Trans Male
Nonbinary
Other
Choose Not To Disclose
Preferred Pronouns
Sexual Orientation
Lesbian/Gay/Homosexual
Straight/Heterosexual
Bisexual
Unknown
Other
Choose Not To Disclose
How did you hear about us?*
Google Search
Word of Mouth
Facebook Ad
Referral
Provider Referral
Please select your primary reason for seeking therapy:*
Depression
Anxiety
Relationship Issues
Substance Abuse
Family Conflict
LGBTQIA Topics
Grief Loss
Life Transition
Perinatal Support
Stress Management
Communication Skills
ADHD
Autism Spectrum Disorder
Behavioral
Adjustment/Transition Difficulty
Academic Difficulties
Trauma
Other
Which type of therapy are you seeking?*
Individual Therapy
Couples Counseling
Family Therapy
Other
Select additional reasons for seeking therapy below (check all that apply):
Anxiety
Depression
Relationship Issues
Substance Abuse
Family Conflict
Grief/Loss
Life Transition
LGBTQIA
Perinatal Support
Other
Stress Management
Communication Skills
ADHD
Autism Spectrum Disorder
Behavioral
Adjustment/Transition Difficulty
Which quality, if any, is most important to you in a therapist?
Gender
Life Experience
Years in practice
LGBTQIA+ Specialization
Primary Insurance Provider*
Primary Subscriber*
Primary Subscriber Date of Birth*
Insurance Member ID*
Secondary Insurance Provider (if applicable)
Secondary Insurance Member ID
Street Address *
City*
State*
Zip Code*
Are you open to telehealth?
Yes
No
What is your preferred contact method?*
Phone
Email
Text
All of the Above
Preferred Appt Time
Mornings
Afternoon
Evenings
Weekends
Preferred Appointment Days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Is this therapy court-ordered?*
We will call you to learn more in order to match you with the best therapist. Is there anything else you'd like us to know?
Please verify your request*
Submit