Request an Appointment Name * First Name Last Name Email * Phone * (###) ### #### Home Address Date of Birth (month/day/year) Preferred Name Preferred Name (how would you like us to refer to you?) First Name Last Name Your Pronouns (he/him, she/her, they/them) Briefly explain your reason for seeking therapy What are you looking for in a therapist? When are you available for appointments? (e.g. weekday mornings) Preferred Appointment Location In Person in Midtown Virtual First Available How did you hear about Present Mind? Thank you!
