Name *

First Name

Last Name

Phone

(###)

###

####

Therapy Type *

Couples

Individual

Family

Therapist Preference

(Preference cannot be guaranteed)

First Available

Kathryn Rheem, Ed. D., LMFT (Ketamine Assisted Psychotherapy sessions only)

Krista Clark, LMFT

Emily Dowling, LMFT

Nicky Verster, LMFT

Callie Shirts, Licensed Resident in Counseling

Haley Latta, Licensed Resident in Counseling

Time Preference

(Preference cannot be guaranteed)

Morning/Early Afternoon (10am-1pm)

Mid-Afternoon (1-4pm)

Evening (5-7pm)

Anytime

Referral Source *

Online Search

Psychology Today

Therapist Referral

Personal Referral

Name of Referring Therapist

If you were referred by a therapist, please enter their name here. Thank you!

First Name

Last Name