Let’s get to know one another.

Phone *

(###)

###

####

Would you prefer our treatment team reach out to you by email or phone? *

Phone

Email

No preference

Seeking Support for *

Self

Family Member

Child

Person Seeking Support's Date of Birth *

MM

DD

YYYY

What date would you be able to begin services? *

MM

DD

YYYY

Please check all service categories that may apply to your situation: *

Adult Counseling/EMDR

Child Centered Play Therapy/Counseling

Parent Coaching

Family Therapy

Group Counseling (circle of security, social skills, trauma, DBT, mindfulness)

Couples Counseling

Educational Consulting/ Executive functioning training

Yoga/Mindfulness training

Music Therapy

Alternative Healing techniques (energy & Crystal work), Human Biofield Tuning

Adult Occupational Therapy

Youth Occupational Therapy

Nutrition/Dietitian Services

Body Work/Massage Therapy

Professional Coaching and Consultation

Do you plan to use insurance for some of your services? *

Yes

No

Unsure