Become A Client

Date

Month

Day

Year

Full Name

Best Email for Communication

Phone

I am a resident in Maryland.

I am NOT a resident in Maryland.

What Service Are You Interested In?

Please Note: Sliding scale spots are available upon request.

I Identify With The Following Statement.

I currently have thoughts or desire to harm myself or someone else.

I have a history of suicide attempts or suicidal ideation.

Both Apply

None Apply

Are you currently struggling with any of the issues below?

Alcohol Use

Drug Use

None of the Above

Are you willing to participate in a 15 minute introduction call? *All new clients must have a consultation*

Yes, I am willing to have a 15 minute call.

No, I am not willing to have a 15 minute call.

How did you hear about my services?

Yes, subscribe me to recieve email and SMS notifcations.

Please allow 24-48 business hours for a response. If you are experiencing an emergency, please stop and call 911.