Evolve Counseling Co

All therapy appointments take place virtually

Any questions? Concerns? Want to schedule an appointment? Fill out the form below and I will get back to you as soon as I can!

Patient Information

Full Legal Name *

Preferred Name

Gender Identity *

Patient Age *

Date of birth *

I'm currently seeing clients via tele-health in either the state of Utah or Maryland. Due to licensing laws, you must be physically present in the state at the time of session.

State

Utah

Maryland

If patient is under 18 years of age, enter guardian information below.

Guardian Name

Guardian Phone

Guardian Date of Birth

Email *

Primary Insurance Coverage

I don't have any of the above insurance policies and/or I prefer to pay out of pocket

Check here

Briefly describe what you're looking for with therapy

***All therapy appointments take place virtually***

All therapy appointments take place virtually