Request for Therapy Form

Please correct the errors described below.

Hello there! Thank you for taking the time to tell me more about yourself. Please note that this form is confidential and will delivered to me via an encrypted platform. Filling out this form is the first step to see if your therapeutic needs meet with my experience and expertise.

Please note that the completion of this form:

  • does not mean I am your therapist
  • does not mean that I am an appropriate therapist for you
  • does not mean that I have availability in my schedule to receive new clients
  • does not mean that will enter into treatment together

Unfortunately at this time, I do not accept health insurance, and am considered to be a private pay therapist. If your insurance plan allows, you may be able to use my services as an out of network provider. Click here for more information.

If you wish to use your insurance, and you are looking for referrals, I would recommend using the find-a-therapist search engine located on Psychology Today.

Thank you for taking the time to fill out this secure form. Once you click on the "submit" button, it will be delivered to my encrypted email inbox. Upon receiving this information, I will give you a call so that we can discuss this information further.

Thanks, and I look forward to talking with you soon. --Tim

Your information will be encrypted.