Contact with Main Form Embed

Permission to send an email

Yes

No

Permission to leave voicemail

Yes

No

What is your preferred contact method

Email

Phone

Text Message

Any of the above

Sex

Female

Male

Prefer not to say

Age Range of Potential Client

12 and under

13-18

19-25

26-40

41-55

55+

Clinician in mind

Rebecca Townsend

Lisa Syner

Alaina Workman

Reason for appointment

Individual therapy

Couples therapy

Individual Intensive (Rebecca only)

Couples Intensive (Rebecca only)

Clinical Supervision (Rebecca only)

Psychological Evaluation (Rebecca only)

Other

Are you willing to invest between $95-400 per hour for your care? WE DO NOT ACCEPT INSURANCE

Yes

No