Consultation Contact Form

If you are in immediate crisis please call 911, visit your local hospital or dial 988 for the National Suicide Prevention Lifeline.
To get started please complete our contact form and schedule your FREE 15 minute phone consultation.
Name*

First NameLast Name
Pronouns*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
What is the best way to contact you?*

PhoneEmailBoth
Can a voice message be left at the provided phone number?*

YesNo
What is the best time to reach you?*
On the next screen you will be asked to submit a copy of your Photo ID for proof of identity and a copy of your health insurance card to confirm your benefits, if you will be using health insurance to cover your services.

Step 3 of 4
Preferred Therapist by State

Select the therapist of your choice in your state of residence and we will do our best to accommodate your request.
Delaware*
Select "Not Applicable" if you are not a resident of the state of Delaware.
North Carolina*
Select "Not Applicable" if you are not a resident of the state of North Carolina.
New Jersey*
Select "Not Applicable" if you are not a resident of the state of New Jersey.
Pennsylvania*
Select "Not Applicable" if you are not a resident of the state of New Jersey.
How can we help you?
Briefly describe what you would like to accomplish through therapy:*

Photo ID