We look forward to connecting with you.

First Name

Last Name

Email

Phone Number

Age

How Did You Hear About Us? How Did You Hear About Us?Google/Internet SearchGoogle MapsReferred by Medical Provider or TherapistReferred by Friend or Family MemberPsychology TodayZocDocGoogle AdInstagramFacebookOther

Preferred Contact Method Preferred Contact MethodPhoneEmail

Please list your preferred appointment days & times

I’m Interested In I’m Interested In Individual Therapy Couples Therapy Couples Intensive Premarital Counseling EMDR Intensive Naturopathic Medicine Acupuncture Therapy Supervision/Consultation Workshop or Training Event Other

If you selected "other" please list the service your are interested in recieving

Select your provider Select your providerAlice Veirs, NDEmily Burnham, LAMFTKeely Puchalski, NDKerstyn Ludlow, MFT InternNick Puchalski, LMFTOther/Open

Briefly describe your current needs