Name * First Name Last Name Email * Phone * (###) ### #### What services are you interested in? Talk Therapy Creative Therapy I don't know Group Coaching When would you like to recevie a complimentary 15 minute consultation? Available days are Tuesday through Friday. And upon availability. You will be contacted via e-mail to set up a time that works for us both. MM DD YYYY Payment Method * Indicate if you are with OHP or paying cash. OHP - non Trillium - CareOregon is no longer accepted. OHP - Trillium Cash - Full payment Cash - Financial assistance requested Private or commercial Insurance How did you hear about me? Psychology Today Referral from another therapist Internet Search I looked for a creative therapist and found you Divine intervention Message If you have additional information to provide please do. Thank you! Let’s work together
