Your Name (adult client or caregiver)(Required) First Last Email(Required) Phone(Required)Client's Name (if different from above) First Last Client's Date of Birth(Required) MM slash DD slash YYYY I am interested in: Individual Counseling Couples Counseling Family Counseling Individual Music Therapy Preferred Method of Payment(Required) Self-Pay Insurance Your Insurance Plan (if preferred method of payment)Please describe why you are seeking counseling and/or music therapy services.(Required)Please provide your availability (days/times) for scheduling sessions.(Required)Preferred Session Type(Required) In Person Zoom Δ
