Let’s work together Name * First Name Last Name Pronoun(s) Phone (###) ### #### Email * Preferred Start Date MM DD YYYY What kind of therapy are you seeking? Individual Therapy Couples/Relationship Therapy Marathon Therapy Do you have any concerns about your physical safety, whether due to your own thoughts or actions, or because of someone else? Yes No Please describe your current concerns and what you're seeking in a therapist. Please note: While I am not the best fit for individuals currently experiencing high-risk suicidal ideation or concerns related to physical violence, you are welcome to complete this form, and I can provide referrals to providers who can help. If you're unsure whether this applies to your circumstances, you may provide more details below and I will assist you. * How did you hear about me? When are you available for therapy sessions? Please list your preferred days and times. Thank you!
