Your First Name

Your Last Name

Your Email Address

Your Phone Number

Please acknowledge that emails and text messages should not contain sensitive information. Please acknowledge that emails and text messages should not contain sensitive information. I understand that emails and text messages are inherently insecure, could possibly be read by third parties, and should not contain sensitive information.

What is your preferred method of contact? What is your preferred method of contact? Email Text / SMS Phone

Why are you seeking therapy at this time?

Who referred you?

We do have a sliding scale fee that is determined based on income and number of dependents. If you are interested, please provide your annual income and list who you are financially responsible for.

How did you hear about us? How did you hear about us?Search engine (e.g. Google)Current or former client (e.g. friend, family member)Therapist, psychiatrist, or physicianInsurance companytherapy-collective.comPsychology TodayZocDocOther

Who referred you?

What additional information would you like to provide?