Name *

First Name

Last Name

Phone Number *

(###)

###

####

Please select the therapist you would prefer to see if applicable

Talya Bradford, LCPC

Christina Daly, LCSW-C

Will Willis, LCSW-C

Sarah Payne, LCPC

Chelsea Turner, LMSW

Lindsay Smith, LCPC

Alexandra Ling, LCSW-C

Jeni Jenshoej, LCSW-C

Rachel Lovett, LCSW-C

Ellen Lischin-Smith, LCSW-C

Timothy Perry LGPC

No Preference

How would you like to be seen?

In person only

Telehealth only

Both

No preference