New Clients

Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What type of service are you looking for? *

Select any that apply

Therapy

EMDR

Coaching

I'm not sure

Do you prefer in office visits or telehealth? *

In Office

Telehealth

Both

Will you be billing insurance or paying cash? *

Insurance

Cash