Let’s connect.

Name of Client *

First Name

Last Name

Client's Date of Birth

MM

DD

YYYY

Client's phone *

(###)

###

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Name of parent/guardian (if client is a minor)

First Name

Last Name

Phone number of parent/guardian (if client is a minor)

(###)

###

####

How would you like to be contacted? *

Text me to schedule

Call me to schedule

Email me to schedule

What are you experiencing? We presently provide INDIVIDUAL therapy for kids ages 10+, adolescents, teens and adults. *

Please check all that apply.

Anxiety/Panic

Depression/Feeling Low

Loss/Grief

Stress

OCD

Adjustment to Life Changes

Neurodivergence/ADHD concerns

Trauma/Effects of Trauma

School/Job Stress or Struggles

Perfectionism/People-Pleasing Patterns

Anger/Irritability/Agitation

Perinatal/Postpartum Concerns

Parenting/Adjustment to Parenthood Stress

With whom would you like to schedule? *Present openings are daytime spots only.

Sarah Pottle

Krupa Desai

Katie Higgins (waitlist only)

No preference

Please select one *

I have BCBS PPO or BCBS Blue Choice (not HMO) and plan to use it

I plan to do self-pay

I have an out-of-network insurance and would like to use my out-of-network benefits