Your Name *

First Name

Last Name

Partner Name (if applicable)

First Name

Last Name

Primary Phone Number *

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Type of Therapy Desired *

Psychoeducation Session or 3rd Party Consultation

Individual Counseling

Couples Counseling

Other

Mental Health History *

Currently In Therapy

Engaged In Therapy In The Past

Current And/or Past Mental Health Diagnosis (Please Include Diagnosis In The Client Message)

Family Mental Health History

History of Addiction