Contact Us
If you are a new client and are looking to set up a consultation, please fill out the form below. Please note: do not use this form to disclose personal health information or to get help in an emergency. If you need immediate help, please call 911 or visit your nearest emergency room.
Sign in to Google to save your progress. Learn more
Email *
Name *
Phone Number *
Please briefly describe what you need help with. *
What insurance do you have? 
Please note we do not accept medicare / medicaid at this practice.
Clear selection
What kind of appointments are you looking for?
Clear selection
What is your preference for appointment days and times?
9-12
12-3
3-6
Open / Flexible
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Is there a certain therapist that you want to see?
Are you okay with being added to our waitlist?
Clear selection
Thank you for contacting us!
We will get back to you as soon as possible via email to discuss scheduling. Take care!
Please note that we receive a high number of referrals and it may take us some time to get back to you. Feel free to email us at info@spilltheteapsychotherapy.com if you do not hear back within a month of submission. Thank you for your patience!
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy