First and Last Name

Your email

City

State

Date of Birth

Gender
FemaleMaleNon-BinaryOther

Phone Number

Type of Therapy You Are Interested In
Individual TherapyCouples TherapyFamily TherapyCase ManagementAdvocacy

Service(s) You Are Interested In
Partner YogaTrauma Informed YogaTherapeutic Yoga for Mental HealthEnergy Healing/ReikiIntegrative Nutrition for Mental Health and Well BeingMeditation
Other:

Group Therapy
Navigating MenopauseAdults with Childhood Sexual Abuse HistoryParents with Teen ChildrenParents with Bullied Children and Trauma Histories
Other:

School Workshops
Identifying and Supporting Students with TraumaBullyingStress managementSchool Work and Personal Life BalanceUsing Social Media Responsibly and Safely (Students and/or Teachers/Staff)Signs of Sexual or Other Abuse
Other:

Workplace Workshops
Work Life BalanceCoping Strategies for Stress managementCreating a Positive Workplace EnvironmentRespecting Diversity
Other:

Briefly describe your concerns and what is causing you to seek therapy and/or specific services: