Name *

First Name

Last Name

Phone *

- Please provide a phone number where you may be reached, in case email is not going through. - For a phone number outside the US, please include a WhatsApp or Signal number. - If you don't have a safe number, please feel free to type "0." Please note, if there is a tech glitch or typo in the email address field, you may not receive a response without a number as backup. Thank you for your care.

Country

(###)

###

####

Voicemail *

Are you comfortable and is it safe to receive a voicemail at this number?

Yes

No

Text Response *

Are you comfortable and is it safe to leave a text follow-up at this number?

Yes

No

Were you referred? Please select all that apply. If you were referred by a medical professional, please have your provider email me directly, if possible, as well.

by a community group, member or friend

by a medical professional /therapist (please provide their name below)

other

What kind of services or support are you seeking? *

Please feel free to check the closest response. If you have a question, please put that in the additional notes field.

Individual Weekly Ongoing Sessions and/or to be added to the next openings list (wait times can range from 1 day to 6 months, depending on availablity)

Shared Sessions for Partners, Couples, Siblings, Families, Small Groups

For Health Professionals: Individual Case Consultation in applied Intersectional Feminism, Integrative/Functional Care, or for working with Clients with Complex Trauma, Addiction or Grief

For Health Professionals: Group Case Consultation Sessions, as available

For Organizations and Trainers: Embodied DEI or Restorative Amends and Repair Consultation and/or Training

Intensives Waitlist *

Would you like to be added to the on day intensives waitlist?

Yes, please add me to the intensives waitlist

No, I am interested in other support

Workshops, Special Topic Trainings, Retreats and Publications *

Once in a while, we will offer a workshop, special topic training, online or in-person retreat, or have a publication. Would you like to receive an update about these?

Yes, please.

No, and thank you.

Your name *

First Name

Last Name

Are you the point person or coordinator for your organizations event?

Yes

No, I will specify the coordinators/contact person's name below.

Event Coordinator's Name

First Name

Last Name

Event Coordinator's Phone number *

(###)

###

####

Is your event hosted online (via Zoom or other web broadcast platform)? *

Yes

No

Event Updates

Would you like to be added to my mailing list to receive batched updates? I send them very sparingly, once or twice a year perhaps.

Yes, please include me in your updates.

No thanks, I am not interested to be included at this time.