New Client Information

Thank you for your interest in working together. If you are ready to get started and would like to see if this work is right for you, please fill out this form and I will reach out to you via email to discuss how we might move forward.

I will respond to every inquiry, so if you don't receive a response from me, please check your spam folder.

I'm looking forward to meeting you! - Jake

First name

Last name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

How did you hear about me? (If it's a referral, please tell me who sent you.)

What specifically brings you to this work?

Are you currently working with any other traditional or non-traditional forms of therapy to manage stress or emotional/psychological issues?

Yes

Are you currently on a medication to manage depression or any other psychological issue?

Yes

Are you currently being treated by a physician for any condition or illness (mental/emotional/physical)?

Yes

I have read and agree to all Terms outlined on the Informed Consent page of this website. Informed Consent

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