Secure Contact Form

My Information

First name

Last name

Email address

Phone number

How did you hear about us? Who referred you?

I'm interested in:

Therapy Services for myself

Therapy Services for my child

Marriage/Relationship Therapy

Family Therapy

Skills Training (for ADHD, emotions, etc)

Please explain below.

Leadership, Wellness, Burnout Prevention Trainings or Similar

Please explain below.

Other

Please explain below.

If you selected any of the last 3 choices, please explain:

Partner's or Child's Information (If counseling needs are for/with them)

Partner's/Child's First Name (Ignore if therapy is for you)

Parner's/Child's Last Name (Ignore if therapy is for you)

Parner's/Child's Date of Birth (Ignore if therapy is for you)

Can we contact you by phone, email, and voicemail?

yes

If no, what is your preferred method of communication?

Does the person needing services have insurance or will they be cash pay? Please be aware, we do not accept Medicade at this time.

Cash Pay

Insurance

Enter Insurance Infomation Below

Something Else / Does Not Apply

If Insurance, what type, ID and Group Number? If none, type N/A

If Child's Insurance, what is the parent's name and date of birth that carries the insurance? If none, type N/A

Reason for Inquiry

Describe the reasons you are seeking therapy.

If you clicked other, why type of therapy are you looking for?

Do you have a specific counselor/trainer/behavioral skills coach in mind?

If that particular individual or a Licensed Professional Counselor isn't available, would you be interested in seeing or using a graduate level student or an LPC-Associate at a cheaper rate?

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