New Client Appointment Request

The form below is for first-time, new client appointment requests only.   While appointment requests are reviewed regularly, it is not intended for immediate response.

If you are submitting this request on behalf of someone else, please provide your name/contact number in one of the comment fields as well.

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 legal name:
Date of birth:
Your email address:
Your phone number ###-###-####:
Best days and times for appointments:
Preferred gender of therapist:
Name of 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?

(note that you will be returned to a blank form after pressing the button above)

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

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