Request a Free Consultation

Name:*
E-mail Address:*
Cell Phone:
Home Phone:
Work Phone:
Other Phone:
Best way(s) to reach you to set up consult/appointment:
Best time(s) of day for consultation:
Best day(s) for consultation/appointment:

Are you currently under the care of a therapist/counselor?
Yes No

Are you currently on any psychiatric medications?
Yes No

Preference for Initial Consult
Phone Office

If you are currently having thoughts or impulses to harm yourself or anyone else, you should call 911 or go to your nearest emergency room.

(Please note office consultations will be part of a normally scheduled 60-90 minute Initial Evaluation with first 30 minutes free.)

Please describe your present concerns and how I may be of help to you:




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