Contact Your Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone (###) ### #### City and State of Residence Are you a previous client? Yes No Would you like to use insurance? Yes No Therapist You Would Like To See Bernie Andrews Terry Armandi Lori Dziedziak Serena Jacobs Lauren Pratt Sara Ralph Melea Sayward Jessica Shinton Liz Somsanith Annie Wald What type of therapy are you interested in? In-Person Telehealth Hybrid No Preference Please briefly explain what brings you to seek therapy at this time. When are you available for appointments? Please list days and times. How did you hear about us? Thank you!
