This form will help you get focused on exactly what you want to discuss during our call, and it will help me get familiar with you and your current circumstances.

All information is kept strictly confidential.


Fill out this form and send by click the button at the bottom. You can also print and fill out this form by hand and either scan and email it to me ( or fax it to 866.927.7002.


Once I have reviewed your submission, you will receive an email with how to schedule your conversation with me. After you choose a date and time, you’ll receive a confirmation of your appointment via email.