New Client Appointment Request Form

First Name

Last Name

Email Address

Phone Number

Date of Birth for Individual Seeking Counseling:

We are not scheduling sessions for children under age 8. If interested in parenting support, please use parent's Date of Birth.

Scheduling Availability (Please include any daytime availability if applicable):

Briefly, what brings you to counseling? For family therapy, we start with one identified client. Once the individual client has started therapy, the client and therapist can make a plan for incorporating family therapy sessions.

For minor clients, does your child have a parent that lives outside of your home? If so, please share custody information and if both parents consent to starting therapy:

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