Use the form to request an appointment.
To expedite process please send the follow information. Telehealth Only!

Name of Insurance Carrier and ID#, DOB, Current Availability, Reason Seeking Counseling.

Please Note:

****There are limited appointments available *** We do not keep a wait list, you should check back in 2-3 weeks for new openings.

Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Are you a new patient?

Yes

Service

Select a type of service

Name of Carrier and Insurance ID# and DOB, Reason for counseling

Cancellation Policy: To avoid a $80 fee, notify us at least 24 hours prior to your appointment to cancel or reschedule.