REQUEST AN APPOINTMENT

If you’re interested in booking an appointment for individual counseling please fill out the form and I will be in touch with next steps.

If you would prefer we chat over the phone first for a free 15-minute consultation, feel free to contact me via text or by phone to set up a time for us to discuss if I could be a good fit for the treatment you are seeking.

For inquires about Nurtured by Nature Therapy group events, please submit a form or reach out directly via email.

Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

Gender Identity

Preferred Pronouns (she/he/they/ze/xe/other)

Inquiring about

Psychotherapy (45-minutes)

Psychotherapy (60-minutes)

Group Events

Availability

Monday-Friday (10am-7pm)

What primary concerns are you seeking treatment for?

(Ex. anxiety, depression, relationship concerns, etc.)

List any medications you are currently taking

(including over the counter)

Do you have any medical conditions?

Have you ever attempted suicide?

Yes

Have you ever been psychiatrically hospitalized?

Yes

If yes when, where, and for how long?

Do you currently use an illicit substance or abuse prescription medications?

Yes

If yes please list illicit substances used

Do you have any legal issues?

(such as arrests, warrants, DWI, DUI, DWAI, probation or parole)

Insurance Plan

N/A if you plan to pay out of pocket

Referral Source

Google Search, Friend or Family Member, Doctor or Agency, etc.

REQUEST AN APPOINTMENT

NURTURED SELF THERAPY