Name *

First Name

Last Name

Please indicate which area applies to you:

I identify as a First Responder/Frontline Worker

I am recently diagnosed with a mental health issue

I am a caretaker or support person of a loved one living with a mental health or aging related issue

I am interested in Individual Therapy

I am interested in Couples Therapy

I am interested in Coaching

I am interested in coordinating a Training/Speaking Engagement