First name

Last Name

Email address

Telephone Number

Do you prefer we contact you via phone or email?
---EmailTelephone

What times of day are you available for appointments?
---Mornings before 11amAfternoons between 11:30a-3:30pEvening 4p-8pSaturdays

What's bringing you in?

Relationship Transitions:

Breakup/DivorceDatingRelationship(s)Self-RelationshipCouples CounselingPremarital

Life Transitions:

Stress/AnxietyDepressionGrief & LossCareerPhase of Life ChallengesTraumaOther

Do you have insurance?
---Blue Cross Blue Shield PPOBlue Cross Blue Shield Blue Choice AdvantageUnited Behavioral Health / OptumUnited - Veterans Affairs Community Care NetworkSelf-PayOther - Out of Network Insurance

Any messages or questions you'd like to include?

Please leave this field empty.