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Name

First Last Initial

Email (please use same email at the end in our scheduler)(Required)

Confirmations will be sent

Phone(Required)

Used to schedule consultations

Which state do you live in? (Required due to State Licensing Laws)(Required)

Which services are you interested in?

Couples Counseling

Individual Partner Counseling

Pre-marital Counseling

Something Else

What is your preferred venue?

In-Person Only

Video Telehealth Only

Either

Therapist Preference?(Required)

Specific Therapist Alexandria(Required)

Specific Therapist Charlottesville(Required)

Specific Therapist Fairfax(Required)

Specific Therapist Leesburg(Required)

Specific Therapist McLean(Required)

Specific Therapist Reston(Required)

Specific Therapist Short Pump(Required)

Specific Therapist VA Telehealth(Required)

Specific Therapist Washington DC(Required)

Specific Therapist Telehealth DC(Required)

Specific Therapist Bethesda(Required)

Specific Therapist Columbia(Required)

Specific Therapist Frederick(Required)

Specific Therapist Rockville(Required)

Specific Therapist Telehealth MD(Required)

Specific Therapist Cary(Required)

Specific Therapist Charlotte(Required)

Specific Therapist Wilmington(Required)

Specific Therapist Telehealth NC(Required)

Specific Therapist Charleston(Required)

Specific Therapist Mt. Plesant(Required)

Specific Therapist Telehealth SC(Required)

Specific Therapist Winter Park(Required)

Specific Therapist Telehealth FL(Required)

Specific Therapist for WV resident (Leesburg office)(Required)

Specific Therapist for WV resident (Frederick office)(Required)

Specific Therapist Los Angeles(Required)

Specific Therapist Pasadena(Required)

Specific Therapist CA Telehealth(Required)

Have you reviewed our pricing information and out-of-network status with insurance?

Yes

No

Please click here to visit our fees and insurance page. This should help answer your questions before talking with someone.

You will now be sent to our consultation booking where you can select a 15 minute block for a telephone call.
It's important you use the same email used on the first page of this form. Thanks!

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