Name *

First Name

Last Name

Inquiring about:

Please check which service you are interested in.

Individual Therapy

Relational Therapy

Professional Consultation

Other

I am interested in working with: *

Please select the provider you would like to work with.

Marissa Stein, MS, LMHC, CST, NCC

Claire Brinkley, Student Intern

Whoever has current availability

I have read about the rates & insurance policy of this practice *

Please tick the circle to acknowledge.

Yes, I have read about clinician rates & understand that the clinicians at this practice to not take any form of insurance.