New Client Appointment Request

The form below is for first-time, new client appointment requests only.  You may also call us toll-free at (855) 458-4966 to request an appointment. While appointment requests are reviewed regularly, it is not intended for immediate response. Please allow up to 48 hours after submission for a response.

If you are experiencing a mental health emergency, please call 911 for an immediate response.


Your name:
Date of birth:
Your email address:
Your phone number(###-###-####):
Best days and times for appointments:
Insurance or EAP company
Insurance Member ID (if applicable):
What issues/concerns are prompting you to seek therapy/counseling at this time, and how long have you been experiencing them?
Have you had any therapy/counseling in the past? If so, did you find it helpful?
Have you ever had a psychiatric hospitalization?
Have you ever experienced suicidal thoughts, and acted in any way on those thoughts?
What medications are you taking for depression/anxiety/other mental health issue?

If you are experiencing a mental health emergency, please call 911 for an immediate response.

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