First Name * Last Name * Pronouns Email Address * Phone Number * May we leave a message? * Yes No What is your preferred method of contact? * Phone Email Primary Client Name If you are filling this out for someone else, please include their name and age here. What is your relationship to the primary client? Myself My Child My Partner Other I'm looking for: * Individual Therapy Family Therapy Relationship Therapy Group Therapy Other I'm looking for help related to: * Eating Disorders and Disordered Eating Chronic Dieting Body Shame and Body Liberation LGBTQ+ Sex and Sexuality Gender Identity Depression Anxiety Stress Relationship Concerns (Individual) Relationship Concerns (Therapy with Partner or Family) Shame Resilience and Self-Compassion Mindfulness and Meditation Trauma and PTSD Substance Use Adolescent Development and Parent Coaching Grief / Loss Other If you selected "Other" please share more about what you are looking for: My preference is to work with: * Please connect me with the person best suited to my needs. These qualities are most important to me in a therapist: * Warm and nurturing Calm and slow-paced Friendly and direct Focused on skill-building Youthful Sense of humor Life experience Fat-positive Sex-positive LGBTQ+ affirming Poly-affirming Kink-affirming Incorporates mindfulness and meditation Engaging, interactive style Integrates art, music and creativity Trauma-responsive If a reduced fee rate is available, please indicate what fee range would work for you: $75-$85 $90-$105 $110-$120 Other My preferred appointment times are: * Weekday Mornings Weekday Lunches Weekday Afternoons Weekday Evenings Saturdays Sundays Please select as many as possible to help with scheduling. How did you hear about us? * Is there anything else that you would like us to know?