Your Name *

First Name

Last Name

Phone *

(###)

###

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Who do you think could benefit from therapy? *

Check all that apply

Myself alone

My spouse alone

My son/daughter alone

Someone else alone

Myself and my partner (couples therapy)

Myself and my son/daughter (family therapy)

Other relational therapy

Would you like for me to call you for a 10 minute consultation? *

If not, I will simply respond via email to schedule an appointment.

Yes, please call

No, we can coordinate via email.

If you choose to schedule an appointment, would you want an online of in-person appointment in Abilene? *

Online (clients must be in Texas)

In person at the Abilene office

Either online or in person

If you choose to schedule a full appointment, which days/times would work best?

NOTE: Not all times may be available. Please check all that apply.

Wednesdays (8 AM - 1 PM)

Thursdays (8 AM - 1 PM)

Fridays (8 AM - 1 PM)

Fridays (1 PM - 4 PM)