Name *

First Name

Last Name

Phone

(###)

###

####

Preferred method of contact *

Phone

Email

What therapeutic services are you interested in? *

Select all that apply

Individual Therapy

Couples Therapy

Clinical Supervision

Perinatal or postpartum support

Fertility or loss support

Consultation or a phone introduction

What payment option are you interested in? *

Use Independence BC Insurance

Private Pay

Private pay and provide a superbill

I’d like to learn more about my options

Preferred starting date *

MM

DD

YYYY