Name *

First Name

Last Name

Phone *

(###)

###

####

How often would you like to meet? *

Weekly

Bi-weekly

What services are you interested in? *

Relationships & Attachment Counseling

Anxiety & Depression Counseling

Coaching

Intensives

Other

I understand sessions start at $215 per session. Therapy is private pay; I can provide superbills you can submit for possible out-of-network reimbursement. *

I acknowledge