Therapy Consultation Request

Name

First Name

Last Name

Pronouns (ex: She/He/They)

Phone

(###)

###

####

What support are you seeking?

How did you hear about me?

Please select from the drop-down list below

Do you have BCBS or UNITED HEALTH insurance?

Please briefly share what you are seeking therapy for?

Please note: This form is not intended for any urgent communication. Legally and ethically, I cannot provide clinical support to people I have not established a therapeutic relationship with. If you are experiencing a personal emergency, please consider contacting an urgent health care facility and/or crisis service.

Therapy Consultation Request

Thank you for completing the form. Charles will contact you within 7 business days.