Contact
Client Consult Form
What Are You Interested In?
(Required)
Individual Counseling
Couples Counseling
Hold Me Tight Workshops
Your Name
(Required)
First
Last
Email
(Required)
Enter Email
Confirm Email
Partner's Email
Leave blank if seeking individual therapy
Your Phone Number
(Required)
Partner's Name
Leave blank if seeking individual therapy
First
Last
Preferred Contact Method
(Required)
Phone/Text
Email
No Preference
Preferred Location for Sessions
(Required)
Virtual/TeleHealth
East Bay/Oakland
San Francisco
Either In Person or Telehealth
Please Note Specific Times that Work for Sessions
(Required)
To ensure we can match you with the right therapist to meet your schedule, write the specific days and hours that work for you. If you are couple please take into account your partners schedule as well.
Reasons for Seeking Counseling
(Required)
Communication Skills
Sex and Intimacy
Repeat Arguments
Premarital Counseling
Infidelity / Trust Issues
Other
Preferred Gender of Therapist
Comments
Please let us know any additional information you would like us to know about you and or you and your partner.