Work with Emily

Name *

First Name

Last Name

Phone *

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Date of Birth *

Date of birth is needed to verity insurance benefits

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DD

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Preferred Appointment Day and Time *

Check all that apply.

Weekdays 8am-11am

Weekdays 11am-2pm

Weekdays 2pm-5pm

Reasons for Appointment *

Please check all that apply. If you do not see your reason for attending therapy listed, or want to expand on any of the items listed, please do so below in the message box.

Anxiety

Chronic Pain

Depression

Domestic Violence

Grief

LGBTQ+ Concerns

Life Transitions

Parenting Issues

Relationship Issues

Self-Esteem

Stress Management

Trauma + PTSD

Women's Issues

Other