Name *

First Name

Last Name

Phone

(###)

###

####

What State do you reside in? *

I can provide therapy to KS & MO residents.

Kansas

Missouri

Please indicate the type of support being requested. *

Couple and/or Relationship Counseling

Individual Counseling

Are you familiar with my availability, fees and out-of-network benefits for services (found on the FAQs page)? *

Yes

No