Contact page

First and Last Name

Country of Residence

Cell Phone

Reason for inquiry

How did you learn of my practice? Direct search? Through another platform? Recommendation?

If you live in the US, what is your state of residence

Employed or Student. If you are a student, what is your major and year of graduation

Current living situation

Partner and or family Status

20-30

30-40

40+

If Seeking treatment for OCD, please describe symptoms, age of onset, current severity or type N/A

If seeking for transport/travel anxiety please describe, onset, type of travel/transport, impact on life or type N/A

If seeking treatment for another type of Anxiety Disorder, please describe in detail and include impact and severity or type N/A

Motivation or reason for seeking treatment at this point in time

Please describe current use of alcohol or any other substance

Additional comments