Work with Hannah

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

Sundays 2pm-7pm

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

Bipolar Disorder

Borderline Personality Disorder

Complex Trauma

Consensual Non Monogamy

Couples Therapy

Depression

Divorce Counseling

LGBTQ+ Concerns

Life Transitions

Poly Relationships

Relationship Issues

Religious Trauma

Sexual Identity

Sexual Trauma

Women's Issues