Name * First Name Last Name Email * Phone * (###) ### #### Where did you hear about us? * Facebook/Social Media Google Search GMU My Doctor My Therapist NoVa CC Other Our Website Past/Current Client Psych2Day Returning Client School Staff Speaking Event STBH What therapy services are you inquiring about? Check all that apply * Individual Counseling Family Counseling Group Counseling Virtual/Telehealth In Person Therapy What is your preferred appointment time? * Mornings ( Before 12pm) Afternoons (12pm-4pm) Evenings (After 4pm) Which clinician would you like to see? * Katherine Bolin, M.A Karen Wee, LMSW (Mandarin Speaking Therapist) Tomoko Rose, M.A, CRC, CBIS (Japanese Speaking Therapist) No Preference What state are you located? Virginia Maryland Other How are you going to pay for services? * Insurance Self-Pay Out-of-Network Open Path If Insurance, what do you have? In your own words, what is brining you into therapy? * Thank you for reaching out. Your message is very important to us. Please note that our offices are currently closed so that staff can take time off for some much-needed mental and emotional self-care. We will be back in the office on Monday October 2nd. Schedule An AppointmentWe will try our best to accommodate your request and will be in touch as soon as possible.
