Name *

First Name

Last Name

Phone *

(###)

###

####

Availability

What is your preferred time to meet? We'll do our best to find a time that works for your schedule.

Mid-day (11am - 2pm)

Afternoon (3pm-5pm)

Evening (after 5pm)

I'm flexible, I'd like to hear all options

Session type

Do you have a preferred meeting location?

In person at 1934 Monroe St.

Video via online telehealth platform

No preference

Session frequency

How often would you like to meet?

Weekly

Bi-weekly (every 2 weeks)

Monthly

Payment options *

If you have questions, please refer to our "Fees & Payment" page for further information.

Dean Health Plan / Medica

Dean Medicaid

Quartz Health Solutions

Quartz Medicaid

Self-pay with "superbill"

Self-pay

Please note, while we ask a few questions to help determine if we're the right fit for your needs, these questions are just for screening purposes and to help ensure we can provide the support you're looking for. *

Have you experienced any of the following in the past 90 days? (check all that apply)

Active suicidal thoughts or recent self-harm

Recent psychiatric hospitalization or emergency mental health care

Depression or low mood

Anxiety or overwhelm

Life transitions or stress

Relationship concerns

Grief or loss

Difficulty coping with chronic illness or pain

Recent traumatic experience

This form is not intended to collect protected health information (PHI). Please do not include sensitive medical, psychiatric, or personal information. If you are concerned about privacy, contact us by phone using the number on this page. *

Please confirm:

I understand this form is not monitored 24/7 and is not intended for emergencies.

I understand submitting this form does not create a therapist–client relationship.