Appointment Request Please enable JavaScript in your browser to complete this form.12Client Name *FirstLastClient Email *Client Phone *Location *Memphis, TNLeominster, MAWichita, KSKissimmee, FlSt Cloud, FlIndianapolis, INServices Needed *Couples TherapyIndividual TherapyFamily CounselingGroup TherapyMedication ManagementPsychiatric EvaluationSession Type *In PersonTelehealthBoth – HybridInsurance ProviderPolicy NumberPolicy Holder's NameFirstLastNextWhy are you seeking therapy? *I am depressedI feel anxious/overwelmedI’ve been diagnosed with a mental disorderI’m struggling with relationshipsI experienced traumaI am grievingI want to improve self confidenceI am battling addictionRecommended (by doctor, family or friends)OtherPreviousSubmit
