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Schedule a free 20-minute consultation with me—I’ll answer your questions and you can decide if I’m the right therapist for you.

600 N 36th St Suite 220
Seattle, WA 98103

Name

First Name

Last Name

Phone

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I am seeking services to help with:

Burnout, Anxiety, Perfectionism

Processing a Breakup

Relationship Stress/Transitions

Childhood Sexual Abuse

Something else (describe below)

Is there anything you'd like to share with me prior to our conversation?

Note: Please do not include Personal Health Information or comments you'd prefer to keep confidential on this form.

How did you find my services?

Google, Psychology Today, Referral, etc.