Name * First Name Last Name Email address * Phone number * (###) ### #### Preferred contact method * How would you like to communicate with me? phone call email text Substance abuse or addiction issues * Do you or your partner have substance abuse or addiction issues? Yes No Appointment availability * When are you generally available to meet? Appointment preference * Would you prefer to meet in-person at my office or virtually? In-person Virtual No preference Payment Method * How do you plan to pay for appointments? Insurance Self-pay Unsure Comment Add any additional information or questions here. Thank you! I will be in contact shortly.
