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.

Dynamic Counseling and Coaching Solutions

At Dynamic Counseling and Coaching Solutions we believe whole people connecting with one another enhances the well-being of the family and the community. Similarly, people living and working together as whole communities will make the world better for all of us. To this end, Dynamic Counseling and Coaching solutions fosters the kind of individual growth that comes from intentional change by promoting health, healing and restoration.

Loading...