Contact Form for Services Name * First Name Last Name Reason for Inquiry: * Interested in Individual Therapy Interested in Couples Therapy Interested in Trauma Therapy Intensive Clinical social work supervision Consultation Continuing Education Preferred Method for Contact: * Phone Call Email Text Message Email * Phone * (###) ### #### Insurance and Payment Information: I am interested in using insurance only (please list the name of your insurance in next field) I am interested in private pay and I am aware that your private pay hourly rate for individuals is $200 or $300 for couples, which I can comfortably afford (no superbills will be provided). I am open to using insurance or privately paying based on the type of service provided. When would you like to begin? If you are interested in using insurance only (please list the name of your insurance): When would you like to begin therapy? * Within the next 3-5 days Within the next 7-14 days Within the next month Preferred Days for Sessions: * (Check all that apply) Monday (12 PM - 6 PM CST) Tuesday (9AM - 4 PM CST) Wednesday (10AM - 6PM CST) Thursday (8 AM -12 PM CST) Where will you be located at the time of virtual sessions? * Alabama Florida Oregon How did you hear about us? * Google Search Social Media Referral from a Friend/Family Member Other (please specify in next field): Please Specify here: Comments or Questions: * Thank you!
