request my appointment

Name *

First Name

Last Name

Phone *

(###)

###

####

Partners Name

For couples therapy only

First Name

Last Name

Partners Phone

For couples therapy only

(###)

###

####

Preferred method of communication *

Phone

Text

Email

How would you like to receive services? *

In-Person Only

Telehealth Only

Open to Both

Are you interested in learning more about a Couples Therapy Intensive?

Yes, please contact me about a Couples Therapy Intensive.

No, thank you.

Would you like first availability or work with a specific clinician?

First Available

Lauren Buongiovanni, LPC (Georgia ONLY)

Andrew Orchowsky, LCMHCA

Mary Chalk, LCMHCA

Jana Ullrich, Intern

Aaron Stamper, Intern

Carole Cullen, LMFT

Andrea Kinnaugh, LMFT

Katie Blasko, LMFTA

Would you like someone from our Client Care Team to contact you?

Yes, please!

No, thank you.

How did you find out about us so we can help other people? *

Google Search

Google Sponsored Ad

Facebook

Instagram

Referral

Psychology Today

Gottman Referral Network

Mailer

Other

Out of Network Insurance Acknowledgement *

My-Therapist is an Out-of-Network Insurance provider. Please click below to acknowledge that we do not submit claims to insurance. We are able to provide you with a superbill that you can submit for out of network reimbursement. *

I Acknowledge

Email and Text Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to My-Therapist, Inc. therapists and/or office staff communicating with me via email or text message. DISCLAIMER:By providing my phone number to My-Therapist, Inc., I agree and acknowledge that My-Therapist, Inc. may send text messages to my wireless phone number for any purpose. Message and data rates may apply. Message frequency will vary, and you will be able to Opt-out by replying “STOP”. For more information on how your data will be handled please see our privacy policy below: PRIVACY POLICY:No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.

I Consent