Request An Appointment Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of Birth *Email *Phone *Primary Insurance *Is this Medicaid or Medicare? *YesNoSecondary Primary Insurance (if applicable)Is this Medicaid or Medicare?YesNoTherapy Request *IndividualCoupleAdolescentPlayFirst RespondersFamily TherapyPresenting Concern *DepressionAnxietyTraumaCommunicationBehavioral ConcernsSpiritual/Faith-based ConcernsOtherPlease briefly describe your concernWho would you like to see?Licensed Professional CounselorsNoneIlsa ArakiFred SelbyShannon HoggSteve PruittAmanda WilliamsTabatha LamunAsiyah DeGruyKim MarsolanStephanie JohnsonProvisional Licensed Professional CounselorsNoneMechelle PollardKearstin Sanders-MorganLauren ThibaultAmber FieldsKayla PetoneMadison ThompsonLauren McDougalFaith MunsellShanique HarrisonCelia FranksIntern or Practicum StudentNoneAlex ArendalEmily BurglassTim RobertsWere you referred to us by anyone?Submit
