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Therapy Service Waitlist
Please complete this form to be placed on the waitlist for therapy services with Brittani Strozier, LMFT.
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Email
*
Your email
Phone Number
*
Your answer
Today's Date
*
MM
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DD
/
YYYY
Name
*
Your answer
Age
*
Your answer
How did you hear about Grounded Hues Therapy & Wellness?
*
Therapy for Black Girls
Psychology Today
From a current client
Instagram
Facebook
Website/ Web search
Other:
Which therapy service would you like to receive?
*
Individual Therapy
Couples Therapy
Group Therapy
Please briefly describe your reason for seeking therapy?
*
Your answer
Do you currently reside in Georgia or the District of Columbia?
*
Georgia
District of Columbia
Other:
*Please note: at this time, services are only available to residents in Georgia or DC.
What is the best way to contact you?
Email
Phone
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