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Name *

First Name

Last Name

Phone

(###)

###

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What services are you looking for? Please check all that apply.

Individual Counseling

Relationship Counseling

EMDR Therapy

Play Therapy (ages 5-12)

Other

Preferred Therapist

Monica Molt, LPC (Not Currently Accepting New Clients)

Morgan Sutton-Cavender, LPC (Current Waiting List)

Jacob Tutwiler, LPC

Andrea Newell, LPC (Child and Adolescent Therapist)

Alexis Winsor, MEd

Date of Birth

MM

DD

YYYY

Payment Preference

I plan to use insurance

I prefer to self pay

I'm not sure yet

How Did You Hear About Us?

If you were referred by a professional or organization, please include their name in your message below

Referral from another therapist or medical professional

Referral from an organization

Word of mouth

Web search

PsychologyToday.com

Other

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