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. After I receive this form, we will make arrangements to talk further via the telephone.

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

It is also important to note that, unfortunately, I don't take health insurance, and am considered to be a private pay therapist. If using your insurance is important for you, and your insurance plan allows, we can explore the possibility of using my services as an out of network provider.

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.