Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth (of client) *

This helps to give you access to the client portal should you schedule an appointment.

MM

DD

YYYY

Best Time For Appointment? *

You are able to select multiple times

Morning

Afternoon

Evening

Do you prefer a male or female counselor? *

Female

Male

No Preference

Who are your preferred counselors? *

If you choose "no preference" you will be placed with a counselor based on your availability and what you're looking for.

Whitney Blakely

Braden Norton

Bree Miller

Mary M. Petro

Tori Davidson (Child Counseling)

No Preference