Name

First Name

Last Name

Phone *

(###)

###

####

Do you have a therapist you prefer or have been referred to? *

None/First available

Beth Houle, PhD LMFT (Virtual only)

Jennifer Weller, LMFT

Alicia Boggess, LMFT

Lara Kate Todd, LMFT

Crystal Fawley, LMFT

Maddie Storz, LMFT (Virtual only)

Courtney Liljekvist, LMFT (Virtual only)

Bailey Spradling, LMFT

Ali Goodman, LMFT

Preferred Location *

Open to in-person or telehealth

In-person only

Telehealth only

What services are you seeking? *

Check all that apply

Individual Therapy

Couples Therapy

Family Therapy

Play therapy