Name:

    Phone:

    Best email to reach you:

    How did you hear about me?

    In what ways has your life been limited by trauma, fears, grief or worry?

    What are the top 3 things that you’d like to accomplish in therapy?

    What is your current trade or occupation?

    How do you intend to cover costs of therapy?

    Private pay $185.00 for intake $150 for sessionsOut of Network Benefits (pay what insurance does not cover)

    What is a good day and time to reach you?

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