Name *

First Name

Last Name

Phone *

(###)

###

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Type of Therapy Seeking *

Individual Therapy

Child/Adolescent Therapy

Couples Counseling

Family Therapy

Setting

In-Person

Virtual/Telehealth

Hybrid

No Preference

I am interested in working with: *

Erin Smith, LPC (Aetna, Private Pay)

Emily (Nash) Villarreal, LMSW (Private Pay Only)

Marissa Sanchez, LMSW (Private Pay Only)

No Preference

Acknowledgment *

At this time, we are only able to offer services to clients residing within the state of Texas. Please confirm that you plan to attend sessions in-person or virtually from a location within the state.