Name *

First Name

Last Name

Phone

Optional. Please fill out if you prefer a call to follow up

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Preferred method of contact

Email

Phone Call

Are there any specific issues or specialties you're looking for support with? *

Check all that apply

Anxiety

Depression

Trauma/PTSD

Relationship issues

ADHD

Parenting

Burnout

Greif/Loss

Identity/Cultural concerns

Life transitions

Other

Do you have any therapist preferences? *

No preference/Soonest available

Amanda Keogh

Angelique Guina

Belen Calkins

Jane Livingston

Robin Lemke

Sarah Fletcher (waitlist)

Preferred session format *

In-person (Bellevue)

Telehealth

No preference

Preferred days/times *

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Morning (8am-11am)

Midday (11am-2pm)

Afternoon (2pm-5pm)

Evening (5pm-7pm)

Flexible

Do you plan to use insurance or private pay? *

Private pay

Using insurance