Full Name *

Phone *

Email *

City *

State *

Whom are you seeking counseling for? *

When are you regularly available for therapy? *

What's the best way to contact you? *

Which therapist are you looking to see? *

Who is your employer? *

What is your Lyra Code? (if applicable)

Briefly describe the issue you would like to work on. *

Email Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to The Center for Mental and Sexual Health therapists and/or office staff communicating with me via email or text message.

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