First Name *

Last Name *

Phone *

Email *

May we leave a message? *

Yes

What is your preferred method of contact for scheduling? *

Phone

Who are you contacting us about? *

Myself

A minor child

An adult dependent

Other (please specify below)

Who are you contacting us about: Other (if applies)

Primary client name (If you are filling this form out for someone else, please include their name here.)

What is your age? *

What is your relationship to the primary client? *

Myself

My Child

My Partner

Other (please specify below)

What is your relationship to the primary client: Other (if applies)

What kind of therapy are you seeking? Please choose all that apply. *

Adult Individual Therapy/Counseling

Adolescent Individual Therapy/Counseling

Child Individual Therapy/Counseling

Adult Neurotherapy (Neurofeedback)

Adolescent Neurotherapy

Child Neurotherapy

Neurofeedback Mentoring/Training

Do you know which counselor you’d like to see? *

Sean Brock

Karen Klismet

Leah Raulerson

Carrie Buechner

Nicole Bradley

I don’t know

‍Get to know our counselors here.
(If the therapist you choose is not accepting new clients, we’ll help you get connected with another provider.)

Please let us know what you’d like to work on in a few sentences. You can reference the list below if it’s helpful to you.

Do you have specific scheduling needs? *

I have a flexible schedule.

I prefer certain appointment times (please specify below).

Weekday Mornings

Weekday Lunches

Weekday Afternoons

Weekday Evenings

What are your payment preferences? (Please choose all that apply.) *

I plan to pay privately.

I would like a superbill for counseling services to request reimbursement through my provider.

How did you hear about our practice? *

Web Search

Current Healthcare Provider (doctor, psychiatrist - please specify below.)

Friend or Acquaintance

Current Client

Psychology Today

Other (please specify below)

How did you hear about our practice: Other (if applies)

Current Healthcare Provider (if you marked the option above)

Is there anything else you'd like us to know at this time?

I agree to the Privacy Policy provided by the company. By providing my phone number, I agree to receive text messages from the business.

Captcha