Contact Me

Name

First Name

Last Name

So I can follow up with you. I'll never share or spam.

Phone

(###)

###

####

Preferred Contact Method

How would you like me to follow up?

Telehealth or in-person preference

Do you plan to use insurance?

What would you like support with?

(Feel free to check one or more, or leave blank — we’ll talk more if we connect.)

Anxiety / burnout

Perfectionism or people-pleasing

Body image or relationship with food

Identity / neurodivergent support

Trauma / family dynamics

How did you hear about me?

Anything else you want to share?

Totally optional — this could be about your availability, accessibility needs, identity info, or anything else you’d like me to know upfront.