WAITLIST

Thank you for your interest in therapy. At this time, I am not accepting new clients, but you are welcome to join my waitlist. If space becomes available, I will reach out to discuss next steps. Completing this form does not guarantee an appointment. If you are in need of immediate support, please consider reaching out to another provider or a crisis resource.

Name

First Name

Last Name

Phone

(###)

###

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Briefly describe what brings you to therapy

You may briefly describe what you're seeking support for. Please note: This form is not HIPAA-compliant, so for your privacy, we kindly ask that you do not share any sensitive personal health information.

Insurance

Please specify which insurance plan you have