Let’s work together! Please fill out the following information and I will be in touch shortly. Name * First Name Last Name Email * Phone (###) ### #### Age * What is your insurance? (If not using insurance, please indicate.) * Please briefly describe the types of concerns you want to work on (e.g., anxiety, relationship issues). * What days and times are you available for appointments? * Thank you! I will contact you within 1-2 business days to discuss next steps.