First and Last Name (required)

Your Email (required)

May we contact you by email? (required)

YesNo

Phone Number (required)

May we leave a message for you at this phone number? (required)

YesNo

What type of counseling service are you requesting? (required)

Couples CounselingIntensive Couples CounselingPremarital CounselingIndividual CounselingIntensive Individual CounselingParent Support CounselingTeen CounselingFamily CounselingEMDR TherapySomatic Experiencing TherapySand Tray TherapyWorkshopGroupCoaching Program

If registering for a coaching program, workshop, or group, please select it below:

Reconnecting With Your Whole Self Coaching ProgramCouples Communication I GroupCouples Communication II GroupFrom Surviving to Thriving: Group for Those Experiencing Anxiety and DepressionFrom Surviving to Thriving: Group for Helping ProfessionalsModern Moms GroupParenting Skills GroupGet It Girls GroupHold Me Tight® Workshop for CouplesBefore 'I Do' Preparing for Marriage GroupStrengthening Your Inner Champion With Self Compassion GroupModern Moms WorkshopParenting Skills WorkshopBefore 'I Do' Preparing for Marriage Workshop

Partner’s Name (optional- for couples counseling)

Partner’s Email (optional- for couples counseling)

Partner’s Phone Number (optional- for couples counseling)

Fee Requested

Please select the fee based on your ability to pay and what works for your personal budget and finances. No verification of income or proof of need for sliding scale services is required.

Insurance
We are an out of network provider. We can provide a receipt (called a superbill) that you may be able to submit to your insurance for out of network reimbursement. Please check with your insurance to see what your mental health coverage is.

(Note- The first session, also known as the intake session, is 80 minutes in length for all couple and family appointments. This allows us plenty of time to discuss your needs and goals. Fee for the 80 minute intake session is: $250)

Fee for our sessions:

$185 per 50 minute session$270 per 80 minute sessionGroup FeeWorkshop FeeCoaching Program Fee

I need the following appointment schedule:

Weekday AppointmentWeekend Appointment on Sunday

If you need your appointment scheduled for a specific weekday, weekday evening, or time of the day on the weekend, please indicate your preference below.

We are only offering video sessions:

Video session (through secure client portal)

I want to address the following issues in counseling:

Communication ConcernsConflict in RelationshipDivorce/End of RelationshipDepressionAnxietyManaging Overwhelming EmotionsTraumaAddiction/RecoverySelf-EsteemPersonal EmpowermentFinding Work-Life BalanceYoung Adults / Young Couples in 20s and 30sAdults / Couples 50+Premarital CounselingPrepare / Enrich Premarital CounselingFamily Relationship(s) / Family of Origin IssuesPerformance Concerns for AthletesInfidelity in RelationshipLGBTQ Relationship ConcernsSexual HealthSexual ConcernsMulti-cultural / Intercultural IssuesCareer or Work ConcernsGrief & LossFamily of Origin IssuesTeen CounselingExpecting/ New ParentsAdoptionParenting SupportParenting Teens with Behavioral TroublesStep parenting and Blended FamiliesDifficult ChildhoodFinancial ConcernsOther

How did you hear about us? (Website, referral, etc.) (required)

Is there other information you would like to provide?

Notice regarding email communication

This form will be submitted to Relationships Matter Therapy via email message. Email is a convenient form of communication, but confidentiality of the information submitted cannot be guaranteed due to email providers storing information on their servers. It is possible that your form submission could be viewed by a third party. By submitting this form, you are acknowledging the risk, however unlikely, that may be involved in submitting this form.

I have read the statement above regarding submission of this form and acknowledge and agree to its contents.

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