Name *

First Name

Last Name

Phone

(###)

###

####

*

I am seeking

Relational Therapy (2 or more people)

Individual Therapy

*

I am aware that Haunted Hearts Healing does not currently accept any insurance, and that I may request a super bill.

*

I am aware that Haunted Hearts Healing is currently telehealth only

Would you prefer I first try to contact you by phone or e-mail? *

Phone

E-mail (Please check your spam folder as sometimes the e-mail can wind up there)