Name *

First Name

Last Name

Phone

(###)

###

####

In which state do you reside? *

Please note that I am licensed in Kansas and Massachusetts, and I can provide psychological treatment only to residents of those states. If you are requesting consultation, let's discuss further.

Kansas

Massachusetts

Other

Are you hoping to use insurance to cover your services? *

I am not an in-network provider for any insurance company, but I am able to provide the necessary documentation for getting reimbursement if you have out-of-network benefits.

Yes

No

I'm not sure yet

What are your ideal time(s) for an appointment?

Weekday morning

Weekday midday or lunch hour

Weekday afternoon