New client inquiry

If you are interested in beginning your therapy journey, please complete the following information and we will get back to you shortly.

Client Name

First Name

Last Name

Name of parent/guardian (if applicable)

Phone

(###)

###

####

Email

Patient Date of Birth

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Payment method

Cash/ out of pocket

Insurance

Please give a general description of what you are wanting services for

Subject

*Please note that our initial communication with you will likely come via email, so keep an eye out. Because of the amount of time we spend with clients, it is much easier for us to touch base with you electronically to get initial information. Thank you for understanding.

New Client Inquiry

Location

Hours

Contact