To Waitlist

Request to be on waitlist

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Reason(s) seeking therapy (2-3 sentences or phrases is enough) *

Name(s) of Insurance or write "self pay" *

Can you do the initial intake and at least some of the subsequent appointments in the Northampton office? *

Are you residing in Massachusetts? (I can only work those living in Massachusetts) *

Submit