Request an Appointment

Please fill this form out in its entirety to request an appointment. This form does not guarentee an appointment. I will reach out to you shortly after your information has been received.

Please note that this form is not for crisis needs. If this is an emergency please call 911 or go to your local hospital.

Client Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Client Age*

Will you be in Massachusetts during each telehealth session?*

Will you be using insurance?*

If you will be using insurance, what insurance will you be using?*

What is your availability?*

What are some of the reasons you are seeking therapy?*

How did you hear about me?*

BY CLICKING THE CHECKBOX BELOW I UNDERSTAND THAT CONFIDENTIALITY CANNOT BE GUARENTEED VIA COMMUNICATION THROUGH ELECTRONIC MEDIA.*

➤ location

North Shore Constructive Counseling LLC

Telehealth appointments only. All clients must be physically located in Massachusetts.

Office Hours

By Appointment

☎ Contact

olivia@northshoreconstructivecounseling.com