Please complete the following form to request your FREE, online telehealth counseling session(s). 

  • The effective period of service availability is 30 Nov 2020 until 7 Feb 2021 (10 weeks).
  • Services are delivered via SimplePractice, a fully HIPAA-compliant telemental health platform. 
  • Additional intake forms and materials will be provided when your initial appointment is scheduled. 

Your personal information will not be shared. This information is required for scheduling purposes.
Your personal information will not be shared. This information is required for scheduling purposes and for emergency contact reasons.
Appointments available Tues-Fri from 6pm-9pm and Sat-Sun from 11am-9pm on a first-come, first-served basis unless otherwise arranged in advance.
Please be aware that this form is not a secure form and the information shared is not encrypted or protected. With this in mind, please provide general rather than specific information.