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?*
Email
This field is for validation purposes and should be left unchanged.