Name *

First Name

Last Name

What type of support are you looking for?

Individual therapy

Couples therapy

Family therapy

Group therapy

What type of presenting problems are you experiencing?

Check all that apply.

Feelings of sadness, experiencing less joy in life

Feelings of worry that are hard to put down

Self-worth or self-esteem issues

Communication struggles

Infidelity

Withdrawal from one partner/family member

Cyclical patterns

Other