To schedule a therapy appointment or to request additional information, fill in the form below:
*
Name
*
Phone Number
Alternate Phone Number
*
E-mail Address
*
I am interested in
(Check all that apply)
Indvidual Therapy
Freedom Therapy Group (men)
Couples Therapy
Three Day Intensives (couples)
Three Day Intensives (men)
*
Have you been in therapy for
compulsive sexual behavior before
Yes
No
If so, when and with whom
*
The best day to schedule appointment
Select Day
Monday
Tuesday
Wednesday
Thursday
Friday
Any Day
*
The best time of day for appointment
(Note: Evenings are reserved for groups and weekends are reserved for Three-Day Intensives)
Select Time
Early Morning
Late Morning
Early Afternoon
Late Afternoon
Any Time
*
Briefly explain the reason for your appointment
*= required information