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Name *

First Name

Last Name

Phone *

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I'm interested in help with...(check all that apply) *

Child/Adolescent Therapy

Family Therapy

Group Therapy

Individual Therapy

I'm not sure but I would like a consultation

Disclaimer *

Disclaimer 1: While we make efforts to keep your information confidential, it is important to note that this form is not HIPAA-compliant and should not be used to share sensitive or confidential personal health information. By submitting this form, you acknowledge and accept these limitations on confidentiality Disclaimer 2: By submitting this interest form, I understand that this does not create a therapeutic relationship, it only indicates an interest in a client-therapist working relationship. Disclaimer 3: If you are in a mental health crisis or emergency, you are deeply valued and are not alone. Before calling 911: If you or someone you know is in immediate, life-threatening danger and decide to call 911, please be aware that police are not always equipped to offer mental health support and may even pose danger to Black, Indigenous, and People of Color, Transgender, Mentally Ill, Neurodivergent, and Disabled People. For alternatives please consider exploring options listed at https://dontcallthepolice.com/las-vegas/

I understand and accept