Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Full Name *Please enter your full name as it appears on your identificationEmail Address *A valid email address for confirmation of your preferencesPhone NumberYour contact number for any follow-up questionsPreferred Therapy Type *Individual Session - 50 minuteIndividual Session - 90 minuteWrite to CharlotteLow Cost TherapyOther(please specify in the field below)Please select your preferred type of therapyOtherMultiple Choice *OnlineTelephoneBriefly describe your reason for seeking therapy:Have you previously received any form of therapy?YesNoIf yes, please specify the type and duration:Any specific goals or outcomes you hope to achieve? Have Preferred Information Preferred Session Days *WeekdaysWeekendsMorningsAfternoonsEveningsSelect the days that work best for you.Additional Information or Comments:How did you hear about us?Please let us know where you found us. Submit