Book a Session NowBooking a session is quick and easy. Fill out the form below to request your session, and we’ll get back in touch with you to schedule your time. "*" indicates required fields Step 1 of 9 11% What type of relational support are you looking for?* Premarital Counseling Couples Therapy Couples Therapy for Betrayal Discernment Counseling – when one or both partners are considering divorce Individual Therapy for Relationship Issues Family Therapy Sex Therapy Step Parent & Step Family Trauma Therapy & EMDR Gender Identity Chronic Illness of Self or Family Member Perinatal Maternal Health Other Please Specify Experience in Therapy* I am a first timer and do not know what to expect! I have a current diagnosis I am currently take medication for a mood or behavioral diagnosis I understand the process I am eager to start I want to go slowly Other Please Specify Any Important Preferences in Choosing a Therapist? (Check all that apply) Older (45+ years) Experienced (20+ years in profession) LGBTQIA+ Therapist Christian Based Therapist (We do not identify as a Christian based counseling center. However, certain therapists weave religion into sessions if wanted.) Non Religious Military Experience Male Therapist Female Therapist No Preference Do you have a preferred therapist in mind Yes No Which therapist? Please check any that apply and you are comfortable sharing: I am active duty I am a veteran I am disabled I am retired I am unemployed Finances may be an issue In a relationship but partner does not want therapy at this time If choosing Individual Therapy, what led you here today ? Choose all that apply. Feeling depressed Feeling anxious or overwhelmed Dealing with relationship issues Dealing with the end of a relationship/break Up Building & maintaining relationships Grieving a loss Currently experiencing a crisis or trauma Resolving past trauma Understanding & improving myself Parenting or coparenting Not sure what to work on or where to start Other Please Specify If choosing Couples Therapy, what led you here today ? (Choose all that apply.) Improve communication Resolve conflict Learn to argue constructively Decide to separate or divorce Infidelity Improve intimacy Parenting or coparenting Blended family issues Divorce mediation Understand myself & my partner better Deal with past hurt Discuss a difficult topic Other Please Specify What is your current relationship status? In a relationship Not in a relationship Engaged Married Separated Divorced Widowed Polyamorous It's complicated Are you and your partner(s) currently living together? Yes No Have you had previous Couples Counseling? Yes No Is there anything we need to know about this experience? Yes No Please Specify Name* First Last Partner's name (if applicable) First Last Phone*PLEASE NOTE: If we need to contact you via phone, you will receive a call from a (757) area code. We are legally required to ensure we are speaking with you before identifying the practice over the phone. Partner's phone (if applicable)Email* Partner's email (if applicable) What is your age?*What is your partner's age? (if applicable) What are your preferred days for a session?* Monday Tuesday Wednesday Thursday Friday Weekends What is your preferred time for a session?* Morning Afternoon Evening Which therapy option works better for you?* In-Person Sessions Online/Telehealth Sessions Norfolk East Beach Office Norfolk Waterside Office Williamsburg Office New York Office How did you find out about us? Internet Search Facebook Physician Friend Church Insurance company Psychology Today Other Please Specify If you were referred, who can we thank? Finally, any special considerations that will help us help you?NameThis field is for validation purposes and should be left unchanged.
