Name:

Email Address:

Phone Number:

What are your preferred days/times for appointments?

Self pay or Insurance? What is your insurance plan?

Are you comfortable with telehealth? (this practice is 100% telehealth) Are you comfortable with telehealth? (this practice is 100% telehealth)YesNo

How did you hear about us?

What are your reason(s) for seeking counseling? Please be brief, you don't need to provide details.