Name *

First Name

Last Name

Phone *

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What services are you interested in? (select all that apply) *

Individual Therapy

Gender Affirming Services

Support Groups

What are you hoping to get out of therapy? (select all that apply) *

Create healthier relationships

Heal from intimate partner violence/domestic violence

Explore gender identity

Understand relationship to substance use

Learn healthier & safer coping tools

Heal from systemic oppression

Obtain a WPATH letter for gender affirming surgery

Set boundaries in relationships

Understand a diagnosis of Post Traumatic Stress Disorder or Complex PTSD

Improve relationship with self

Learn skills for assertive communication

Manage or reduce thoughts of suicide or self-harm

Connect with others who are healing from unhealthy & abusive relationships

Learn to manage hallucinations, delusions, paranoid thinking

Heal from childhood trauma

Learn tools for coping with chronic pain and health issues

Increase safety in relationships

Explore medical aspects of gender transition

Break intergenerational patterns of harm

Understand a diagnosis of Borderline Personality Disorder

Live a more authentic and meaningful life

Do you prefer to meet in-person, via telehealth, or both? (select all that apply) *

In-Person

Telehealth

If you wish to use your health insurance to cover the cost of therapy, please check the insurance plan you have, or write in one not listed here.

Optum/United Behavioral Health

Out-of-network coverage

Other (please write in the text field below)