Name *

First Name

Last Name

Phone *

(###)

###

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Choose One: *

I am seeking services for myself and I am over 18.

I am seeking services for someone under 18.

I am seeking services for a family member or friend who is over 18.

What services are you seeking? *

Individual Counseling

Intuitive Eating Coaching

Group Counseling

Would you like to schedule your first session at this time? *

Yes

No

Is there a certain time of day you require for an appointment?

Flexible

Morning

Afternoon

Evening

Please check the box below indicating you understand I am not in network with insurance. Please see my Q&A page for more information about my fees and submitting superbills for reimbursement if you have out of network benefits.

Yes I understand.