Therapy Interest Form
Please complete the information on this form if you are interested in working with me (Lexi Gross) when I return from maternity leave at the end of July.  There will be options for sharing your interest in individual and group therapy. Plan to hear back from me via email or phone at the end of July.
Sign in to Google to save your progress. Learn more
Name:
Where are you located? I am only licensed to provide therapy in North Carolina and Oregon
Clear selection
How do you plan to pay for services?
Clear selection
What days and times are you available for therapy? Please select all options. The more availability you have the easier it is to add you to my schedule.
What type of therapy are you interested in at this time?
What are general reasons for considering working with Lexi Gross? (Check all that apply)
Please provide your preferred contact method (email, phone number for call or texting).
I understand that Lexi Gross Counseling PLLC only offers virtual therapy services at this time and by deciding to work together, you will be working virtually. 
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms