Name *

First Name

Last Name

Phone *

(###)

###

####

I am filling out this contact form on behalf of... *

myself

other (please explain in the "message" box below)

I am looking for... *

Individual counseling

Couples' counseling

If you are looking for individual counseling, who would you like to work with? *

Adam (waitlist for new clients)

Bridget (waitlist for new clients)

Meghan (waitlist for new clients)

Zoe (waitlist for new clients)

I'm not sure yet

Are you planning to use insurance? *

Just to get one question out of the way!

ASR

BCBS

BCN

Optum

Priority Health

United Healthcare

Other

No insurance, cash-pay

What time of day works best for your schedule? *

Select all that apply

Mornings

Early afternoons

Late afternoons or early evenings

Weekends

How did you hear about us? (select all that apply)

Psychologytoday.com

Internet search

Business card

Caledonia Living Magazine

Referral from a doctor

Referral from a friend or family member