Request Appointment - Welcome to My Practice

You can request an appointment here. Please note that if you do not hear back from me it is likely that I do not have openings at that time. When I am able, I may reach out to you if time opens up within the month that I received your appointment request. Please feel free to re-submit your request as appointments will open unexpectedly or within a few weeks.

Appointment Request Form

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

Name*

Identifying Information
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Telephone*
Date of Birth*
MM slash DD slash YYYY
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.