If you would like to register for a group or have any questions please email me by filling out the form below
Name
Email
Phone
Message
If you would like to join a group or make an appointment for a session please fill out the form below. I will get back to you in 48 hours.
Street Address
Phone number
Best hours to call you
Email address
How do you prefer to be contacted?
Date of Birth
Gender
Reason for seeking help at this time
Have you ever been in therapy?
What type? When? How long?
Why did you stop?
Are you taking prescribed psychiatric medications?
What type and for how long?
Name & phone number of person to contact in an emergency
How did you hear about me and/or the group?
