Full Name *

Parent or Guardian’s Name (if a minor)

Age *
5 - 12 years old13 - 18 years old19 - 30 years oldOver 30 years old

Email *

Phone

Preferred Mode of Contact *Please let us know the best way to get in touch with you!PhoneTextEmail

Is there a specific provider you were referred to or would like to see?
No PreferenceGinny PiletereHaylie MerchenJanay O'ConnorJasie BoydJoy OcheKat NazaroffKatie BrouMarisol SaenzRachel Plympton

Primary Concern(s) *This information is used to help match you to a provider, and will not be shared or stored.Addiction / RecoveryADHDAngerAnxiety / StressDepressionEmotional DysregulationGriefImpulse ControlLife TransitionMarital / Relationship ChallengesMedication ManagementNutritionSelf Esteem / IdentitySleep DisordersSpiritualityTraumaOther

How did you hear about us? *
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I understand that Cypress Counseling & Wellness does not accept insurance, except for psychiatry services provided by Joy Oche. Please read more (link above form) to understand the reasons for this policy and how it benefits you.