Request an Appointment

We are unable to provide Emergency Assistance and/or Crisis Response.

If this is an emergency:

call 911
or visit your closest emergency room

Client Information

First name

Last name

Email address

*Please note, by sharing this information you are giving this provider permission to contact by email.

Phone number

*Please note, by sharing this information you are giving this provider permission to contact by phone and/or text message.

I'm already a client

Date and Time

When are hoping to start and days available for sessions...

Please share general days Mon-Fri available for appointments here.

Times of day available for sessions...

Appointments are 50-55 minutes.

About Your Appointment

In a brief sentence or two, please describe the reason you are seeking a therapy appointment.

**Please note, this is not a crisis service and we can only provide scheduled outpatient therapy sessions. If this is an emergency, please call 911 or visit your closest emergency room.

Are you currently or have you ever been treated for any mental health conditions by a medication provider?

Age, sex, gender, relationship status, number/ages of children (if applicable), current occupation.

Current or past legal struggles, current court cases or any pending litigation? If so, briefly describe.

Please note: We are not able to provide court-ordered therapy, or alcohol or substance use disorder counseling, or provide any custody or placement recomendations.

Have you seen a therapist in the past? If so, when was the last time and what did you find helpful and not as helpful?

Your information will be encrypted.

Request an Appointment

We are unable to provide Emergency Assistance and/or Crisis Response.

Client Information

Date and Time

About Your Appointment

We are unable to provide Emergency Assistance and/or Crisis Response.

Clarity Counseling PLLC