Name *

First Name

Last Name

Phone

(###)

###

####

Who are you seeking therapy for? *

Myself

My spouse

Couples Therapy (2 participants)

Family Therapy (more than 2 participants)

A family member who is under 18 years of age

A family member who is over 18

What type(s) of therapy are you interested in? *

You may choose more than one option. Note: equine-assisted therapy is not available for individuals or public groups. If you are representing a corporation or recovery center and would like to learn more about equine-assisted therapy options, please visit our equine-assisted therapy page for a separate form.

In-office Therapy

Telehealth Therapy

We are currently in the office on Mondays & Wednesdays with limited appointment availability after 1 PM. Will this schedule work for you? *

Yes

No

I'd like to learn more about your Telehealth options.

Are you able to attend a session at our office located in DeLand, FL? If seeking telehealth services, do you have a reliable internet connection and a secure, quiet location to participate in the sessions? *

Yes

No