Name * First Name Last Name Email * Phone * (###) ### #### Subject * Message * How did you hear about this program? * My therapist referred me My friend told me about it I found it in an online search Michele is my therapist Flyer around town Social media Other Please indicate your preferred method of communication * Email Text Call Thank you! Your registration request has been submitted. Michele will reach out to you in the next week to gather more information and schedule a short 15 minute phone call to ensure that this program will meet your needs.
