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 Biweekly Ongoing Consultation Sessions

Individual Monthly Ongoing Consultation Sessions

Individual Project Based or Ad Hoc Consultation in applied Intersectional Feminism, Integrative/Functional Care, or for working with Clients with Complex Trauma, Addiction or Grief

Group Case Consultation Sessions, as available

An organization, community or group requesting a workshop, training or staffing on a training -- please fill out the form below this with event details

Something else -- please specify above in Additional Notes Field (n.b. we wont be able to respond to this request without a clarifying note above)

Intensive One Day, Half Day or Weekend Training Request *

Would you like to request a one day intensive on a training topic (please note rates are adjusted to the density of the training accordingly)?

Yes, I will specify my request above in the Additional Notes Field

No, I am interested in more of an ongoing hourly type consultation and support relationship

Fun Updates!!! Workshops, Special Topic Trainings, Retreats and Publications *

Please feel free to request to be added to our mailing list here.

Yes, please.

No, not at this time 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.