Secure Contact Form
Please complete the form below to contact us with questions or appointment requests. Providers will respond to requests based on availability and ability to accept new clients. This form is not to be used for emergencies or crisis appointments - In the case of a clinical emergency, please contact your local emergency room or the Suicide and Crisis Lifeline at 988 for 24/7 support.
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First Name: *
Last Name: *
Pronouns:
Date of Birth: *
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Email *
Phone *
State Located: *
Required
Type of Appointment *
Is there a specific provider you are interested in working with? (Note: While not all of our clinicians currently have openings, this information helps us to offer you the closest match possible). If you'd like to learn more about our providers, please read more here.
 *
Do you have any specific scheduling needs to be considered in setting up an appointment time (i.e. mornings before 12pm, specific days of the week, etc.) ?
 *
Please share a few brief details about why you are seeking services in order to help us best support you: *
Thank You For Completing Our Secure Contact Form!
Our Client Support Coordinator will be in contact with you within 24-48 business hours. They will let you know if there is an appointment available or offer you an option to join our waitlist.

Thank you so much for reaching out and we look forward to supporting you soon!

The Authentic Therapy Services Team
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