Name *

First Name

Last Name

Phone *

(###)

###

####

Type of therapy needed *

Which type of therapy are you interested in?

Individual therapy

Family therapy

Couples therapy

Unsure

How do you qualify? *

Eligibility requirements for the program

Student

Loss of job

Economic hardship

Other

Availability *

When are you normally free for an appointment? Choose all that apply.

Flexible

Weekdays

Weekends

Evenings

Have you seen a therapist before? *

Yes

No

If we currently have a waitlist, would you like to be added to it? *

Yes

No