Name *

First Name

Last Name

Phone

(###)

###

####

Services *

What service(s) are you interested in?

Individual therapy for adults (18+)

Individual therapy for teens (16+)

SPACE (Supportive Parenting for Anxious Chidhood Emotions) - program for caregivers of anxious children

Available days *

I'm available to schedule an initial session on the following day(s), understanding that Carrie may not be able to honor these preferences.

Monday

Tuesday

Wednesday

Thursday

Session times *

I am available to schedule an initial session at the following time(s), understanding that Carrie may not be able to honor these preferences.

9 am - noon

Noon - 2 pm

2 pm - 5 pm

Session preference *

Are you looking for online counseling or in-person?

Online (anywhere in WA)

In-person (Oak Harbor)

Acknowledgement *

I understand the following:

I understand that Carrie only sees individual clients age 16 and above.

I understand that Carrie does not bill insurance companies directly, but will provide a superbill for clients to seek their own reimbursement if their policy allows.