Today's Date *

MM

DD

YYYY

Legal Name *

First Name

Last Name

What name should we use when speaking with you? *

This is sometimes referred to as preferred name.

First Name

Last Name

Phone Number

(###)

###

####

Do you consent to having your sessions recorded? *

Clinical trainees providing psychotherapy services in the ESW Community Clinic are required to video record some or all of their sessions for the purpose of supervision. Sessions are stored securely and destroyed immediately after supervision.

Yes

No

Appointment Availability *

If you are interested in booking an appointment, please select your appointment availability from the options below. Please include all times you are available to help us match you with a clinician. Note: Appointments are currently offered in-office or via telehealth on Mondays, Tuesdays and Wednesdays.

Monday Afternoon

Monday Evening

Tuesday Afternoon

Tuesday Evening

Wednesday Afternoon

Wednesday Evening