Appointment Request

You can request an appointment here. Please note, that if you don’t hear back, it likely means that no openings are available. Feel free to re-submit in a week or so as availability can open up periodically.

Please complete and press the "Submit" button at the end

Name*

Identifying Information
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Telephone*
Gender Identity
- Male
- Female
- LGBTQI+
- Prefer Not to Answer
I am (a/an)
Please describe how you think I can help:
Please tell me the therapist or Primary Care Provider that I might coordinate care with:
(Most Appointments are via telemedicine with some limited In-office appointments starting July, 2020 ) I am interested in:
Insurance*
Preferred day/hours for appointments:
How long have you been experiencing distressing symptoms?
Is there anything else that you would like me to know or have questions about?
Comments
This field is for validation purposes and should be left unchanged.