Contact & Appointment Request Page

Please correct the errors described below.

Please note filling out this form is an inquiry not a guarantee for services. Therapist's availability or other available resources will be sent via email.

***I am a culturally competent and LGBTQIA+ affirmative therapist. I also welcome all spiritual and religious backgrounds but I do not provide specific religious based therapy. I am not currently trained in EMDR therapy

Name

Phone

Age

Days and times available for in person therapy sessions (Sorry I do not provide telehealth)

Where did you hear about me?

Google

Psychology Today

Friend/Family

Insurance website

Have you been in therapy in the past?

Yes

Are you currently in therapy?

Yes

I currently want to work on:

Anxiety

Trauma

Depression

Sexual Abuse

Domestic Violence

Childhood Trauma

Relationship Issues

Infidelity

Mood Disorder

Borderline Personality Disorder

ADHD

Grief

Substance Use

Addiction

Parenting

Disordered Eating

LGBTQIA+ support

Work Stress

Chronic Health or Pain Issues

Anger Management

PTSD

The insurance I want to utilize for sessions is

Iowa Total Care

Blue Cross Blue Shield

UHC

UMR

Health Partners

Aetna

Wellpoint (formerly Amerigroup)

Is there anything else you would like me to know?

Your information will be encrypted.

Please note filling out this form is an inquiry not a guarantee for services. Therapist's availability or other available resources will be sent via email.

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