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Emergency Assistance

If you are experiencing a mental health emergency do not complete this form and go to the nearest hospital or call emergency services.

Dial 911 (USA)
Dial 999 (UK)

What describes you best?

Existing Client Supervisee Referring Provider Other Potential Client

PLEASE COMPLETE TEST DRIVE REQUEST FORM AT https://hushforms.com/test-drive-waiting-list

IMPORTANT: If you are looking to begin therapy and want to set up an initial appointment, PLEASE COMPLETE the Test Drive Request Form instead at https://hushforms.com/test-drive-waiting-list

First name

Last name

Email address

Phone number

Where are you based?

Hawaii, USA London, UK Florida, USA Colorado, USA Vermont, USA

How did you hear about CBT Gym?

NOTE TO COLD CALLERS AND UNSOLICITED COMMUNICATIONS - PLEASE READ.
Please do not complete this form if you are contacting me to sell a service or product for my practice including, but not limited to web design, SEO and any directory listing services.
Unsolicited communications of this sort will be marked as spam, deleted and reported.

For anyone else reaching out for any other matter, please do let me know how I can help in the message box below and thank you for reading the above text!

Message

PLEASE NOTE: 1. Submitting this form does not establish a client-therapist relationship. 2. Unless agreed in advance, do not submit any medical information through this form. 3. I will do my best to reply within 3 business days.

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Emergency Assistance

Emergency Assistance

Justin Miller, LMHC

Cognitive Behavior Therapist, CBT Gym