Therapy interest form

Please complete the secure form below, and you will receive a response within two business days.

Name

First Name

Last Name

Phone

(###)

###

####

Age

Services you're interested in:

Individual Therapy

Couples Therapy

Group Therapy

Intensive Outpatient Program (IOP)

Not sure yet

What brings you to therapy?

Therapy focus or approach:

If you have a preference, what kind of therapy or approach are you hoping for?

Do you have a preferred therapist?

Insurance/Payment

How do you plan to pay for therapy?

Insurance

Private-pay/Cash pay

Not sure yet

Anything Else You’d Like Us to Know?