Name *

First Name

Last Name

Phone

(###)

###

####

Would you prefer to be contacted by phone or email?

I prefer email communication

I prefer phone communication

Can I leave a message?

Yes

No

SMS and Email Reminder Consent *

Somata Psychotherapy offers appointment services, reminders and general business communications by text message and email. If you wish to receive these messages, we require your consent. Please provide your consent by checking the box below after carefully reviewing the terms and conditions available on this website. By agreeing you understand that you will receive text/email reminders and you can contact me at any time to opt out.

I agree to receive automated text messages at the phone number provided in the context of the client/care relationship.

I agree to receive automated email reminders at the email address provided above

I do not wish to receive reminders

Are you interested in telehealth (zoom) or in-person?

I only want telehealth

I prefer telehealth, but am open to in person

I have no preference

I prefer in-person, but am open to telehealth

I only want in-person (in office)