To schedule your first appointment, please complete the new client form by clicking the button below.

Patient Name

First Name

Last Name

Guardian Name

If patient is a minor, please include parent or guardian name

First Name

Last Name

Patient Date of Birth *

MM

DD

YYYY

Presenting Problem *

Select all that apply

Trauma

Depression

Anxiety

Grief

Dissociation

Other

Type of Therapy *

EMDR

Polyvagal

ART

ERT

Somatic

Sensori Motor

Other

I don't know

Scheduling Preference *

Morning

Afternoon

Evening