This form can simplify the process of establishing our relationship. In today's busy world, phone tag can delay scheduling and e-mail can feel impersonal. We offer this form as an option to get your information and concerns directly to us in a more efficient manner. This form is intended for serious inquiries into our services. If you have a general question, please use our contact form for those This form asks for some more personal information so that we can better understand your problems and how we might be able to help. 

Privacy Notice: While we make every effort to keep your information as private as possible, this form transmits your information to us through our website vendor Squarespace. Once we receive the information it is kept confidential. However, the Squarespace system is not secure enough to meet the standards of the Health Insurance Portability and Privacy Act (HIPPA).

Privacy Consent *
I have read the Privacy Notice above and consent to send my information through this system.
Name of Contact Person *
Name of Contact Person
Phone *
Phone
Name of Client (If Different from Contact Person)
Name of Client (If Different from Contact Person)
Client's Date of Birth
Client's Date of Birth
Please select the service you're interested in.
Areas of Concern *
Please tell us some of the problem areas you'd like to address.
Please tell us how you'd like to be contacted.