Name(Required) First Last Initial Email(Required) Confirmations will be sentPhoneUsed to schedule consultationsWhich state do you live in? (Required due to State Licensing Laws)(Required)VirginiaCaliforniaDistrict of Columbia (DC)FloridaMarylandNorth CarolinaSouth CarolinaWest VirginiaWhich services are you interested in?(Required) Couples Counseling Individual Partner Counseling Pre-Marital Counseling What is your preferred venue?(Required) In-Person Only Virtual Sessions Only Either Hybrid Which office location in VA do you prefer?(Required) Alexandria Arlington Charlottesville Fairfax Leesburg McLean Midlothian Reston Short Pump Doesn't Matter (virtual only) Which office location in MD do you prefer?(Required) Bethesda Columbia Frederick Rockville Doesn't Matter (virtual only) Which office location in NC do you prefer?(Required) Cary Charlotte Wilmington Doesn't Matter (virtual only) Which office location in DC do you prefer?(Required) Dupont Circle Doesn't Matter (virtual only) Which office location in FL do you prefer?(Required) Winter Park Doesn't Matter (virtual only) Which office location in SC do you prefer?(Required) Charleston Mt. Pleasant Doesn't Matter (virtual only) Which office location in CA do you prefer?(Required) Los Angeles Santa Monica Doesn't Matter (virtual only) Which office location do you prefer for West Virginia Residents(Required) Leesburg Frederick (Telehealth is not available for West Virginia residents)Therapist Preference?(Required)First Available (Preferred)Specific TherapistSpecific Therapist Alexandria(Required)Alex Honigman (virtual only)Dave WoodenGabrielle de MarcoKelly WilliamsonVictoria WhitfieldSpecific Therapist Arlington(Required)Dave WoodenHolly WillardKelly WilliamsonSpecific Therapist Charlottesville(Required)Glen DenlingerSpecific Therapist Fairfax(Required)Gabrielle de MarcoHeidi LindorfKelly WalkerDr. Marc PatienceMary BakerMichael BorashDr. Paul BirchQuintin TalleyRebecca Kassabian (virtual only)Rebecca StevensonValerie PattonVictoria WhitfieldGlen Denlinger (virtual only)Specific Therapist Leesburg(Required)Alexandra UrbanMary Rainer-SkalaSharon HamiltonSpecific Therapist McLean(Required)Holly WillardSpecific Therapist Midlothian(Required)Michael FronceVictoria IpsenSpecific Therapist Reston(Required)Elizabeth StevensRebecca KassabianSpecific Therapist Short Pump(Required)Melece MeservyMichael FronceVictoria IpsenSpecific Therapist VA Virtual Only(Required)Alex HonigmanAlexandra UrbanDave WoodenDavid GoslingElizabeth StevensErin ThompsonGabrielle de MarcoGlen DenlingerHeidi LindorfHolly WillardJessica CoreyKelly WalkerKelly WilliamsonMary BakerMary Rainer-SkalaMegan GregoryMelece MeservyMichael BorashMichael FronceNicole StoneQuintin TalleyDr. Paul BirchRandi KofskyRebecca KassabianRebecca StevensonSharon HamiltonValerie PattonVictoria IpsenVictoria WhitfieldSpecific Therapist Washington DC(Required)Alex Honigman (virtual only)Lisa Ghali (virtual only)Quintin Talley (virtual only)Holly Willard (virtual only)Dr. Paul Birch (virtual only)Specific Therapist DC Virtual Only(Required)Alex HonigmanLisa GhaliHolly WillardDr. Paul BirchQuintin TalleySpecific Therapist Bethesda(Required)Kate ShepardLisa GhaliQuintin TalleySpecific Therapist Columbia(Required)Dr. Leigh BeckNick Love (virtual only)Specific Therapist Frederick(Required)Jessica CoreyLisa LavittSpecific Therapist Rockville(Required)Kate ShepardLisa GhaliNick Love (virtual only)Specific Therapist MD Virtual Only(Required)Alex HonigmanEllen SingerJessica CoreyKate ShepardDr. Leigh BeckLisa GhaliLisa LavittMegan GregoryNick LoveDr. Paul BirchQuintin TalleySpecific Therapist Cary(Required)Nicole StoneSpecific Therapist Charlotte(Required)Erin ThompsonSpecific Therapist Wilmington(Required)Chae KwakMegan GregorySpecific Therapist NC Virtual Only(Required)Chae KwakErin ThompsonMegan GregoryNicole StoneDr. Paul BirchSpecific Therapist Charleston(Required)Erin Thompson (virtual only)Victoria Whitfield (virtual only)Specific Therapist Mt. Plesant(Required)Erin Thompson (virtual only)Victoria Whitfield (virtual only)Specific Therapist SC Virtual Only(Required)Erin ThompsonVictoria WhitfieldSpecific Therapist Winter Park(Required)Alex Honigman (virtual only)Glen Denlinger (virtual only)Valerie Patton (virtual only)Specific Therapist FL Virtual Only(Required)Alex HonigmanGlen DenlingerValerie PattonSpecific Therapist for WV resident (Leesburg office)(Required)Mary Rainer-SkalaSharon HamiltonAlexandra UrbanSpecific Therapist for WV resident (Frederick office)(Required)Jessica CoreyLisa LavittSpecific Therapist Los Angeles(Required)Sara LoughlinAlex Honigman (virtual only)Specific Therapist Pasadena(Required)Alex Honigman (virtual only)Randi Kofsky (virtual only)Sara Loughlin (virtual only)Specific Therapist Santa Monica(Required)Randi KofskyAlex Honigman (virtual only)Specific Therapist CA Virtual Only(Required)Alex HonigmanRandi KofskySara LoughlinAre you aware we are NOT "in-network" with health insurance companies and you will pay out-of-pocket for our services?(Required) Yes, I understand I will pay out-of-pocket and some reimbursement may or may not be possible (required to finish form) No, I'd like to learn more about your fees & insurance reimbursement policy Please click here to visit our fees and insurance page. This should help answer your questions about costs and reimbursement options. Knowing that we do not accept in-network insurance is required before scheduling or talking with someone. How did you hear about us?(Required) Google search Therapist referral Current/Former client of ours Social Media Other What is the question or phrase you typed into Google that led you to us? (No worries if you don't remember)What is the name of the therapist?How did you find us?Relational Wellness Yes, when you get time to write "relational wellness" blog posts send them to me (just not too many) SMS Consent By checking this box, you consent to receive text messages from Well Marriage Center regarding your inquires or services. You may opt-out at any time by replying STOP. For Assistance text, HELP. Message and data rates may apply. Messaging frequency may vary. Visit https://www.wellmarriagecenter.com/privacy-policy/ for privacy policy and Terms of Service. Δ
