Consultation Request

Let’s get started

Please fill out the form below to get in contact with me and request a consultation for telehealth services!

Name

First Name

Last Name

Email

Insurance

Phone

(###)

###

####

What days and times are you available to attend appointments?

Please note I practice Monday through Thursday

Briefly, what are you hoping to address in therapy? Please indicate your goals

Please do not use this form in the event of an emergency. If you are experiencing a crisis, call 911 or your local crisis team. Information provided via this form may not be secure.

How did you find me?

Please let me know if someone referred you!

I have reviewed all of the information on this site and believe that I would be a good fit for this therapy practice

Yes

Let’s get started

Hope and Resilience VT