*Your Name

*Your Email

*Your Phone Number

*Requested Therapist – (visit Therapists page)
—Gail Randolph-Williams, MDiv, DMin, MFTChristine Shaw, MA, LPCMayra Picos-Lee, MDiv, DMin, LMFTG. Peter Schreck, MDiv, PhDCarol Schreck, MA(MFT), DMin

*Availability (Check all that apply for you – Note: days differ per therapist)
MondayTuesdayWednesdayThursdayFriday(Saturday)

*Times of Day (check all that apply)
MorningNoonAfternoonEvening

Name of Insurance, if planning to submit for out-of-network benefits. (Currently our therapists are out-of-network only.)

*MESSAGE – (Briefly describe the services you are seeking/topic, and your available time ranges. Keep message to a few sentences. This form is NOT for sensitive personal data. Thank You!)