name *

First Name

Last Name

date of birth *

(our practice currently only offers services to adults 18+)

MM

DD

YYYY

phone number *

(###)

###

####

physical home address *

(i.e where you reside/would be participating in therapy from - this is necessary for us to ask as we are only permitted to provide tele-health services to Maine, Vermont + North Carolina residents at this time)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

preferred method of communication *

(how would you like us to reach back out to you?)

e-mail

phone call

text

no preference - any/all of the above

what service are you inquiring about?

individual psychotherapy

trauma-informed care agency training

trauma-informed supervision/consultation

other

is it ok for us to leave a voicemail or send a text message stating our practice name, your name and reason for contact (i.e prospective mental health treatment)? *

yes

no

i'm not sure