Now Accepting New Patients

Your personal information will always be kept private.

First Name *

Last Name *

Phone *

Email *

Indicate your main reason for contacting Jennifer? *

Choose an option

Relationship Counseling
Grief Counseling
Depression Counseling
Other
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Relationship Counseling

Who will be receiving counseling?

Just you

You and your Partner together

You and your Partner seperately

Briefly, what are the main concerns or goals you are hoping to address? *

Check any that apply

Infidelity

Divorce/Seperation

Pre-Marital

Couple Dynamics

Have you or your partner ever participated in therapy before?

Yes

Not Sure

If you could share one or two things you'd like Jennifer to understand about your current situation or what you're hoping to achieve, what would those be? *

Connecting with Jennifer

What is the best way for Jennifer to contact you for a brief, confidential follow-up? *

Telephone

What days and general times are typically best for Jennifer to attempt to reach you? (e.g., Weekday Mornings, Weekday Afternoons, Weekday Evenings, Specific Days) *

Almost done!

Is there anything else specific you'd like Jennifer to know before she reaches out, or any questions you have at this stage?

I understand that submitting this form is an inquiry for services and does not constitute a therapist-client relationship until formally established. I also agree that I am providing contact information so that I may be contacted regarding this inquiry.