Get on the Blackstone Therapy Waitlist!

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for your interest in Blackstone Therapy!

This form is meant to help streamline the process of getting you on our waitlist. It is important to us that you do not lose your spot (and your email doesn't become buried and forgotten about!).

All of the information in this form is confidential and protected by HIPAA and will not be used for any other purpose than to contact you when a waitlist spot opens up for your preferred clinician.

Let us know if you have any questions and don't hesitate to be in touch!

THIS FORM SHOULD NOT BE USED TO REQUEST CRISIS OR EMERGENCY SERVICES.

This form, and it's responses, are not a reliable way of contacting us. We do not monitor this form on a regular basis and it should not be used to make a request for crisis or emergency services.

If you feel like you are in crisis or in need of emergency services, please call 911 or go to your nearest emergency room.

You can also contact the Crisis Hotline by dialing 988 or text HOME to 74174. If you are LGBTQ youth between ages of 13-25 and are in crisis, you can reach out to the Trevor Project. Text 'START' to 678-678.

Please check the box below if you understand and agree to the statement listed. *

I understand this form is not intended to be used to request emergency services.

Required

Clear form

Never submit passwords through Google Forms.

This form was created inside of Blackstone Therapy. Report Abuse

Forms