Treatment Request Form

I appreciate your interest in psychotherapy. A good fit is very important for the success of therapy, and your answers will help me determine if I am the right therapist for you.

  • If you are having a mental health emergency, please call 911 or go to your nearest emergency room.
  • Please do not include personal medical information; this is not a secure form.
  • Feel free to contact me if you have any questions about the form.

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    If yes, what insurance do you have? The listed plans are the ones I accept in network.