Let’s work together

Name *

First Name

Last Name

Phone *

(###)

###

####

What type of counseling are you seeking? *

Individual Therapy

Couples Therapy

Family Therapy

What is your availability for an appointment? *

(Please check all that apply) Weekdays

Early morning (Between 8am - 10am)

Late morning (10am - 12pm)

Early afternoon (12pm - 3pm)

Late afternoon (3pm - 5pm)

Evening (5pm - 7pm)

Weekend (Saturday or Sunday)

Any time / Flexible schedule

What is your date of birth?

MM

DD

YYYY

What is your current location?

Ohio

Michigan

I prefer to be contacted by:

Text message

Email

Phone call