Client Inquiry Form

Your name

What brings you to therapy at this time?

Are you looking for in-person, online or open to either?

Are you planning to utilize insurance? If so, what plan do you have?

Are you looking to work with a specific therapist in the practice?

Are you available for therapy on certain days/times or is your schedule flexible

Please provide you number and email and what state you reside in

Please add any important information you want us to know that we left out

Your information will be encrypted.