Name * First Name Last Name Email * Phone (###) ### #### What services are you interested in? Talk Therapy Creative Therapy I don't know Group When would you like to recevie a complimentary 15 minute consultation? Available days are Tuesday through Friday. And upon availability. You will be contacted via e-mail to set up a time that works for us both. MM DD YYYY Payment Method * Indicate if you are with OHP or paying cash. OHP - non Trillium - CareOregon is no longer accepted. OHP - Trillium Cash - Full payment Cash - Financial assistance requested What is your budget? Please indicate what you are willing to pay. How did you hear about me? Psychology Today Referral from another therapist Internet Search I looked for a creative therapist and found you Divine intervention Message * Without going into too much detail, tell me a little about what you are seeking and why. This portal is secure but is not HIPPA compliant. So don't include information you feel is medically personal. We can go into more detail once we meet. Thank you! Let’s work together
