Request an Appointment

(Secure Video or Phone)

Please correct the errors described below.

Please note: At this time, all counseling and coaching sessions are being conducted exclusively by video (telemental health/telehealth). We will update this form to accommodate face to face therapy requests when they become available again.

Client Information

Date & Time

Please indicate which days work best for you
We offer appointments as early as 8:00 AM and as late as 6:30 PM

About Your Appointment

Please select your insurance carrier or select "none" for private pay/cash.
If there's anything else that you would like me to know prior to your appointment, please include it here.

I understand that I am submitting a request to engage in teletherapy with a clinician employed by Dynamic Counseling and Coaching Solutions, L.L.C. I understand that “teletherapy” includes consultation, treatment, transfer of medical data, emails, telephone conversations and education using interactive audio, video, or data communications. I understand that teletherapy also involves the communication of my medical/mental information, both orally and visually.

Your information will be encrypted.