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Interested in pursuing therapy services with Natalia? Please use this form to get on the waitlist.

First Name

Last Name

Phone Number

Email Address

State of Residence

Client Date of Birth

Pronouns

How would you like to pay for services?

Insurance Type

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Insurance ID

Group Number

What I Can Pay for Weekly Sessions

Best Days to Meet

Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Sundays Any

Best Times to Meet

8a-12p 12p-3p 3p-6p Evenings Weekends Any

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How did you hear about us?

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In general terms, what's bringing you to therapy at this time?

Services Sought

Preferred Therapist?

First Name

Last Name

Phone Number

Email Address

State of Residence

Client Date of Birth

Pronouns

Preferred Method of Contact:

Phone Email Text

How did you hear about me?

Details

In general terms, what's bringing you to therapy at this time?

Services Sought

details

ONLINE + IN-PERSON

BY APPOINTMENT ONLY

+1 (512) 920-5317
[email protected]

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