Let’s work togetherInterested in working together? Please fill out this form and I will get back to you shortly. Name * First Name Last Name Email * Phone * (###) ### #### May we leave you a message? * May we leave you a message? Yes No What is your preferred method for scheduling? * Phone Call Text E-mail Pronouns * Are you a Texas resident? * *Please note I am only licensed to provide services in the state of Texas Yes No What topics do you want to explore in counseling? * Check all that apply Anxiety Depression or Low Mood Grief/Loss Stress Trauma (child onset) Trauma (adult onset) Relationships Family Conflict Parenting Support Prenatal/Postpartum Identity Work LGBTQIA2+ Cultural Experiences Eye Movement Desensitization and Reprocessing (EMDR) First Generation Experience Self-Compassion ADHD PTSD Other Trauma Work Other Do you have specific scheduling needs? * Please select as many as possible to help with scheduling. I have a flexible schedule Weekday Mornings Weekday Lunches Weekday Afternoons How often would you like to schedule session * Select an option Weekly Bi-weekly Monthly Unsure What are your payment preferences? * Choose all that apply. I plan to pay privately. I want to use out-of-network insurance benefits and file a superbill. I want to use my insurance, if possible. I need help with payment options, including how to use my health savings account (HSA). I would like to discuss sliding scale options. Is there anything else you'd like me to know at this time? Please enter Date of Birth (Required if you plan to use insurance) MM DD YYYY How did you hear about Luna Tides Counseling? Thank you for your interest. Your response was received and I will respond within 1-2 business days.
