Alyssa Koelemay, LMSW
About
Connect
Schedule a consultation
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Name
*
Phone number
*
Email
*
I live in
*
— Select Choice —
Texas
Washington
Other
I want to
*
Schedule an new client appointment
Schedule a complimentary 20-minute consultation
Something else
for Phone in
I'm inquiring about services for
Individual adults
Teens
Couples
Other
How can I help?
*
How did you hear about my practice?
*
— Select Choice —
Psychology Today
The Embody Lab
Mindful Therapy Group
Friend
Referral from another provider
Insurance provider
Internet search
AI chatbot (e.g., Chat GPT)
Other
Privacy Acknowledgement
*
I understand that this form is not meant to be a healthcare form, does not fulfill HIPAA privacy standards, and, therefore, should not contain any personal healthcare information. I agree to this information being used by Koelemay Counseling to contact me by email or text message for the sole purpose of establishing further HIPAA-compliant communication as it relates to future healthcare.
Submit
