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Worker with Ladder
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Initial Request

Fill out the form below to help us match you with the right clinician.​

Just click "Submit" when you're done. Thank you!

What services are you seeking? Select all that apply.
Please describe the type of assessment you are looking for? Check all responses that apply.
What languages do you speak ? Select all that apply
Which of the following symptoms have you experienced in the past (no longer present)? Please check all that apply.
Which of these symptoms are you currently experiencing? Please check all that apply.
Are you looking for short term or long term therapy ?
Are you open to meeting online and in-person ? Please note, our in-person sessions are limited.
If we have online only availabilty, are you open to trying therapy online?
Do you have medical insurance ?
Specify covered services if using insurance. Check all that apply. (See insurance contract for details.)


Note: We want to inform you that in accordance with the new laws regarding the protection of personal data, we take the confidentiality of your information very seriously. By submitting this form, you consent to the collection of and agree to the processing of your personal information in accordance with our privacy policy (available on our website). You acknowledge that you have the right to read our privacy policy and contact us if you have any questions or concerns regarding the privacy of your data. Your rights regarding data protection will be fully respected, and we are committed to taking all necessary measures to ensure the security of your information.

Thank you for submitting. 

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