Name *

First Name

Last Name

Phone *

(###)

###

####

I'm interested in help with...(check all that apply) *

Individual Therapy

Child or Adolescent Therapy

I'm not sure but I would like a call back

Disclaimer *

Disclaimer: While we make efforts to keep your information confidential, it is important to note that this form is not HIPAA-compliant and should not be used to share sensitive or confidential personal health information. If you have specific medical or psychological concerns, we encourage you to contact us through secure means or by phone (702-900-8868). By submitting this form, you acknowledge and accept these limitations on confidentiality.

I understand and accept