Interest Form

Submitting this form will add you to our waitlist for individual telehealth counseling with a specialization in chronic illness/pain or cancer. We will reach out to you as soon as we are able to begin scheduling.

Name

Email address

Phone Number

General Availability for Telehealth Appointments Check all that apply

Mornings

8 am - 12 pm

Early afternoons

12 pm - 3 pm

Afternoon/Evening

After 3 pm

Insurance:

Aetna, Blue Cross, Etc.

General reason(s) for seeking therapy:

Your information will be encrypted.