Contact and scheduling

>> Unfortunately, I am currently full and do not have openings for ongoing appointments. << 

Depending on your availability , a spot could open up soon, so please continue reading below.

The form below helps us to start the communication process despite the lack of available times. I may be able to make suggestions, referrals, recommendations, etc. I have this form here to manage expectations about availability; but things are often changing and thus the schedule is not predictable. Without a completed form, I won’t know that you’re looking for support when a spot opens up.

Waiting list form

Please complete this form and I’ll be in touch within 72 hours

Anya0015.jpg
imperfect and enough .png
courage.png
compass
self-compassion
Name
Name
Phone
Phone
Non-conforming, non-binary welcome
How did you hear about me? *
This information is confidential; I will not be reaching out to them. It helps me to understand whether a release form is needed, whether there are potential conflicts of interest, etc.
Please check off all times and days you are available for an ongoing appointment *
This will help me plan ahead and schedule you as soon as I can. If you don't see a window of time that works for you, it is likely that I do not currently have hours at that time. I do not currently offer evening hours.
Preferred methods of contact
It is difficult for me to catch people live on the phone, and vice versa, due to being in session.
I need communication to not disclose reason for contact
If you are concerned about privacy, please indicate how else we can communicate below. Please understand that it is difficult to communicate promptly via phone, and it is helpful to provide windows of time you are available.
Please select your method of payment for services
Please look carefully at the insurances below. *Independence Blue Cross/Personal Choice and Keystone Health Plan East are not the same as Blue Cross/Blue Shield.
I'm looking for the following services:
Check all that apply
Symptoms
{Optional} Please check of symptoms you are experiencing:
What will have changed for you when you accomplish therapy goals?
Emergency *
I understand that if I am having thoughts of harming myself that I need to call 911 or go to my nearest emergency room. This form is not a consent nor a guarantee for treatment.
Please include any other information you feel is important for me to know.