Name *

First Name

Last Name

Phone *

(###)

###

####

Preferred Method of Contact *

Phone

Email

Either

Clinician Preference *

Which therapist are you interested in working with?

Dr. Elyssa Helfer

Lauren Evans, AMFT

No preference

What state do you currently live in? Please note that we can only work with clients who are current residents of the states listed below. *

California

Colorado

Florida

What kind of therapy are you seeking? *

Individual Therapy

Couples/Relationship Therapy

Family Therapy

Unsure/Both