Name *

First Name

Last Name

Phone

(###)

###

####

Providers: *

Please indicate which provider(s) you are interested in working with:

Brenda Banks (counseling via telehealth only)

Jackie Williston (counseling in Bedford/Azle/telehealth)

Kristina Dyer (counseling via telehealth)

Ashley Gordon Prater (counseling in Bedford/telehealth)

Amanda Gatlin (counseling in Bedford/telehealth)

Synde Rogers (aromatherapy, homeopathy in Bedford/telehealth)

Heather Mock (music therapy in Bedford)

Suzy Edmonson (energy work, qigong, craniosacral therapy, SER, OT in Bedford)

Other

I prefer to be seen: *

Please indicate whether you would like to be seen in person or via telehealth.

In-person

Via telehealth

Location:

Please indicate your preferred location for services, if applicable:

Bedford

Azle

I prefer to be contacted by: *

Phone call

Text

Email