Let’s work together.Interested in working together? Fill out some info and I will be in touch shortly! Name * First Name Last Name Email * Phone (###) ### #### Please select your state: Oregon Colorado I am seeking counseling support for: Myself My Child How do you plan to pay for counseling services? Insurance Out of Pocket Unsure If you have insurance, who is your insurance carrier? In order to help me verify availability and fit for services, please share with me some details: * Please tell me a little bit about what is bringing you to therapy. How do you hope therapy can help? * By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Keshet Counseling LLC harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means. Yes, I want to submit this form Thank you!