Hablo Español Contact This form is not HIPAA-compliant. Keep this in mind when submitting personal health information (PHI). * Ok, got it. Name * First Name Last Name Phone * (###) ### #### Email * Please ONLY submit this form if you are genuinely interested in getting started and want to see if we are a great fit/really want to learn more. ***I set aside time to respond to you and save a spot for your genuine interest in getting started! * Got it! Yes, I am motivated and genuinely interested in getting started. How did you hear about us? * Google Psychology Today Medical Referral Word of Mouth Other We are an out-of-pocket practice and we do not bill insurance. * Confirm by typing "I understand": What are you struggling with the most and hoping to get relief around? * Would you like us to reach out to you by texting you or by emailing you? * Text me! Email me (make sure to check your junk mail as well, within the next 24 business hours) Text and email me, please! If you selected to be “texted” above, please type the phone number you want us to text you at OR put “N/A”: * Thank you for filling out this form, we will get back to you in less than 24 business hours! Please make sure to check your junk mail. * Ok, got it! Thank you!
