Name *

First Name

Last Name

Phone *

(###)

###

####

Professional License *

LMSW or LCSW

LPC or LPCA

LMFT or LMFTA

Psychologist

Other

How long have you been practicing as a therapist? *

0-2 years

2-4 years

4-7 years

more than 7 years

Would you prefer to meet online via Zoom or in person in Kim's South Austin office? *

Online

In Person

Either Works for Me

Limited partial scholarships are available for BIPOC folks. Are you interested in applying for this?

Yes

No