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First Name

Last Name

Mobile Phone Number

You agree to receive informational messages (appointment reminders, account notifications, etc.) from WITH Therapy LLC. Message frequency varies. Message and data rates may apply. For help, reply HELP or email us at quanishia@withtherapyllc.com. You can opt out at any time by replying STOP. See Privacy Policy and Terms & Conditions below.

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What service(s) are you interested in?

(select all that apply)

Individual Therapy

Couples Therapy

Group Therapy

Holistic Psychiatric Services + Medication Management

Wellness Consultation (Assessment, Dietitian, Lifestyle)

Integrative Care Plan (Therapy + Wellness/Dietary + Classes Bundled)

Mind-Body Classes

What time of day do you prefer to be contacted?

How would you prefer to be contacted?

*Please note initial consultations require a 15-minute phone call

How did you hear about WITH Therapy LLC?

If therapy is selected, how do you plan to cover sessions?

Please provide a brief message about what you are looking to improve or work through with the selected services:

Please complete the intake form below.

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Contact

Phone: (614) 401 - 6589