Name *

First Name

Last Name

Service Inquiry *

Please select one or more topics of interest:

Individual Counseling

Couples Therapy

Life Coaching

Medication Evaluation

Organizational/Team Consulting

Executive Coaching

Teaching/Speaking

Assessments (Psych Testing)

Other

Available Days *

What day(s) are you available for an appointment? Check all that apply.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

N/A

Available Times *

What are your available times for an appointment? Please check all that apply.

Mornings (0900-1200)

Early Afternoon (1200-1600)

Late Afternoon (1600-2000)

N/A

What is Your Meeting Preference?

Please choose your preferred counseling format (select all that apply):

Telehealth (Video/Phone)

In-Person (Office in Dublin, CA)

In-Person (Office in Walnut Creek, CA)

Telehealth and/or In-Person

Best Time(s) to Reach Out *

When is it the best time to call or text for booking an appointment? Please check all that apply.

Mornings (0900-1200)

Early Afternoon (1200-1600)

Late Afternoon (1600-2000)

N/A: I prefer email exchanges.