CONTACT ME

Please use the form below to book your free initial 15-minute phone consult with me. This brief phone consult is a good opportunity for us to explore whether we are a good fit/match to work with each other. I look forward to answering your questions and helping you decide what’s best for your needs.

Message left through this contact form will be sent directly to my HIPAA-secure email. However, if there is private and personal matter that you wish to discuss, please hold onto it until we join each other for our consult. Please allow up to two business days for me to respond to your request.

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Name:

First Name

Last Name

Email:

Phone number:

(###)

###

####

Interest Inquiry:

Psychotherapy

Consultation

Other

Are you a resident of California, United States?

If you are a resident of United States, please note that per regulations of California state licensing board, I can only provide tele-therapy services to those who are current residents of California.

Yes

No

Are you currently present in California, United States?

Yes

No

Best dates and times for contact (Pacific Standard Time):

Please provide up to three different preferred dates and times for our contact.

What will be your payment method?

Please note that I am an out-of-network provider and do not accept any insurance as direct payment.

Subject:

What's on your mind?

Please let me know what prompted you to reach out to me at this time:

I'm curious. How did you learn about me?

By checking this box, you agree to receive information about my services via electronic communication:

While I do my best to safeguard our electronic interactions to protect your privacy and minimize any security risks on my end, there is never a guarantee that our electronic communication will not be intercepted.

I agree

CONTACT ME

Let’s keep in touch.

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