The Love Within Space | SimplePractice

The Love Within Space Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Reason for care

What is the reason for seeking care?

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What kind of care is being sought?

Individual Therapy Couples Therapy Couples Intensives Support Groups Workshops

Administrative

Inquiry reason

Referral source

Enter how you were referred to our services

Google Psychology Today Social Media Word of mouth Web Directories Printed Marketing Event Therapist Referral

Billing & Payment

Payment method

All services are offered on a private pay basis and are not billed through insurance. I accept all major credit and debit cards. By checking this box, you understand that this is a private pay service and you are prepared to invest in this experience if it feels like a good fit.

I'm ready to move forward if it feels aligned. I'm seriously considering and want to learn more. I'm exploring options and not ready to commit yet.

Client Preferences

Preferred appointment times for consultation.

Morning Afternoon Evening Weekend

Is there anything that the practitioner needs to know?

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.