Next Steps

Preferred Name

First Name

Last Name

Legal Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone Number *

(###)

###

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I'm Interested in working on: *

To your degree of comfort, please check all that apply. This list is not meant to be conclusive, but can give me a sense of how I can help.

Depression

Anxiety

Sexual Dysfunction

Trauma

Eating Disorders/Disordered Eating

Difficulty Controlling Anger

ADHD

Work Related Stress or Burnout

Life Transitions (e.g Separation, retirement, becoming a parent))

Grief & Loss

Marital or Couples Conflicts

Family conflicts or dysfunction

Communication Issues

Intimacy Concerns

Low Self Esteem

Body Image Issues

Identity Explorations/ Concerns (E.g. Queer, racial or cultural identity)

Alcohol or Substance abuse or addiction

Exploring Needs/Wants

Setting Boundaries

Discrimination and/or Oppression

Other...(please describe in the summary box below)

Have you been in therapy before? *

Yes

No

Are you taking any medications at this time? (for medical or psychiatric reasons) *

If yes, I will follow up at your first session. I take a holistic approach to your treatment and coordinate with current health care providers as needed

Yes

No

What Frequency of Sessions are you hoping for? *

Let me know if you're seeking biweekly, weekly, or either. I always recommend weekly as it's clinically more supportive to start.

Weekly Sessions

Biweekly Sessions

Either/Or

Availability *

Please check the boxes for days you are available for sessions

Tuesday

Wednesday

Thursday