Your Phone Number *

(###)

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Client Name *

Name of the person who will be receiving our services

First Name

Last Name

Client Date of Birth *

MM

DD

YYYY

Which counselor(s) would you be interested in working with? *

Not all counselors may have immediate availability but we will try and match you with your preferred counselor where possible.

Devon (Accepting New Clients)

Amanda (Accepting New Clients)

Kathryn (Accepting New Clients)

Eden (Accepting New Clients)

Aleen (Available for Caregiver Coaching)

Brenna (Waitlist Open - not accepting new clients)

Justine (Waitlist Open - not accepting new clients)

James (Waitlist Open - not accepting new clients)

Ali (Waitlist Open - not accepting new clients)

No Preference

What form of session would you be interested in? *

In-person

Virtual

Either in-person or virtual

Would you be interested in sessions during traditional school hours (i.e. before 3pm on weekdays)?

Yes

No