First Name *

Last Name *

Phone *

Email *

Are you requesting services for yourself or someone else? *

Client's Age *

Preferred Therapist (optional)

Your Message *

Email and SMS Text Message Risk Acknowledgement and Use Consent

I understand that the use of email and SMS text messaging is inherently insecure and therefore poses a risk to the security and confidentiality of my protected health information, and I consent to our therapists and/or office staff contacting me via email or text message.

By providing my phone number, I agree to receive text messages from the business.