Name
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First Name
Last Name
Phone
*
(###)
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Email
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Location
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Which state do you live in?
Age
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Are you (or the person you are seeking help for) age 18 or over?
How did you hear about us?
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Therapist Preference
Based on our therapists' profiles, do you have a specific therapist you are interested in scheduling a complimentary 20-minute phone consult? (Please note: some therapists may have a waitlist. We will offer an alternate therapist if your preferred therapist has a waitlist or you may opt to wait but we cannot guarantee a time frame for availability.)
Scheduling Preference
Which of the following best matches your availability for a complimentary 20-minute phone consult?
Therapy Specialtes
Which area of concentration do you identify most closely with? You may select more than one.
Partner's Name
If seeking Couples' Therapy, we will need this information to schedule a phone consult.
First Name
Last Name
What are you seeking to address in therapy that is not included in our list of therapy specialties?
Anything else you'd like us to know or any specific questions we can answer for you?
Are you interested in joining our email list for access to free information and resources?
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