Name *

First Name

Last Name

Phone

(###)

###

####

This is for waitlist inquiry *

yes

no

Type of service requested *

Individual therapy

Family therapy

Parent coaching

Preferred method of service *

Please keep in mind I only offer telehealth sessions for clients 16+. If client is 15 or younger I only offer in-person.

In-person (Bellevue)

Telehealth