Name *

First Name

Last Name

Phone *

(###)

###

####

Do you live in California? *

yes

no

no, but I am moving there soon

I'm interested in attending sessions: *

via secure video

in person (Marin County)

combination of virtual and in person

not sure

I understand that the standard session rate is $235 for a 45 minute session and that this practice is considered out-of-network with insurance companies *

yes

How did you find me? *

online search

therapist or medical provider referred me

personal referral

other