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Therapy inquiry form
Thank you for seeking me for counseling services. Please complete this 2-3 minute contact form to help me get to know you a little better before contacting you regarding therapy.
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Name
*
Your answer
Phone number
*
Your answer
Email
*
Your answer
Seeking services for
*
Individual
Couples
Where are you located?
Louisiana
Texas
New Jersey
Clear selection
Counseling session preference
*
In person-Only for Louisiana residents
Online
Payment method
*
Insurance: If you are using insurance please contact your insurance company to ensure that therapy services are covered. Also, ask if you would need to meet your deductible or will you only have to pay your copay
Private Pay
Reason for seeking services
*
Your answer
Referral Source
Your answer
Submit
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