Name *

First Name

Last Name

Phone *

(###)

###

####

It's safe to leave a voicemail on my phone. *

Yes

No

Which days and times are you generally available for weekly appointments? *

These represent my working hours, not my current availability. When I email you, I'll let you know what appointment times are open.

Tuesdays

Thursdays

I do not take insurance at this time.

I understand all payments will be out of pocket.

What is prompting you to seek therapy at this time? *

Women’s Issues

Spiritual Seeking

Anxiety and/or Perfectionism

Soulful Entrepreneurship