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Quote Jar
Client Portal
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YOUR CART
Waitlist
Please complete the form below to be added to our waitlist. You will receive a welcome email when an appointment/provider becomes available.
*
Indicates required field
Name
*
First
Last
Email
*
Type of Service Requested
*
Individual Therapy
Couples Therapy
Family Therapy
Hypnotherapy
EMDR
You may select multiple options if that applies.
Provider Preference
*
No Preference/First Available
Maritza Barrera, LMFT
Shamina Stagner, LMHC
Alyssa Schwegman, MA
Please note not all providers offer all service types. Please refer to the website to see each provider's specialty if needed.
Preferred Service Location
*
No preference/First Available
In person/In Office
Telehealth
How do you plan to pay for services
*
Self Pay
Insurance
Reason for seeking services
*
Briefly describe why you are seeking services (ex. anxiety, trauma, relationship issues, etc).
How did you hear of us?
*
Please let us know if you were referred by a friend, your insurance provider, website, etc. Thank you!
I agree to receiving marketing and promotional materials
Submit
