Name *

First Name

Last Name

Phone *

Add a good contact number and good times/days to call back.

(###)

###

####

Do you prefer I call you or email you to set up a time to talk? *

Email first

Call first

I am looking for therapy for: *

Myself (an adult)

My child (age 8-17)

Disclaimer *

Disclaimer 1: While we make efforts to keep your information confidential, it is important to note that this form is not HIPAA-compliant and should not be used to share sensitive or confidential personal health information. By submitting this form, you acknowledge and accept these limitations on confidentiality. Disclaimer 2: By submitting this interest form, I understand that this does not create a therapeutic relationship, it only indicates an interest in a client-therapist working relationship. Disclaimer 3: If you are in a mental health crisis or emergency, you are deeply valued and are not alone. In case of emergency, please call 911 or go to your nearest emergency room. National Suicide Prevention Lifeline: 1-800-273-8255 Suicide Hotline 988 (call/text) SafeNest Hotline for Domestic Violence: 702-646-4981

I understand and accept