Preferred Name *

First Name

Last Name

Interested in *

Check all that apply

Individual Therapy

Group Therapy

Relationship or Couples Counseling

Psychiatric/Medication Services

Clinical Supervision or Consultation

Phone *

(###)

###

####

May we text you? *

Yes

No

Meeting preference *

In-person

Video telehealth

Therapist Preference(s)

Check all that apply

No Preference

Allie

Amy

Elliot

Nat

Ocean

Reece

Rod

Taylor

Uri

n/a

Group Preference(s)

Check all that apply

In Full Bloom

n/a

Do you need significant financial assistance?

Yes, I'm interested in working with an intern offering deep sliding scale

Yes, I'm interested in the TJFP scholarship for clients who are both BIPOC and Trans

Yes, I'm interested in the Clarksville Q scholarship for Montgomery County residents

n/a