Name *

First Name

Last Name

Phone *

(###)

###

####

Who are you seeking support for? *

Just myself

Myself + my partner

What would you most like help with? *

Anxiety

Burnout / Work Stress

Low Desire / Intimacy Concerns

Trauma / PTSD

Mental Load

OCD

Pelvic Pain / Sexual Dysfunction

Purity Culture Recovery

Relationship / Communication Issues

Other

What services are you interested in? *

Intensive EMDR

Sex Therapy

Relationship Therapy

Fair Play Coaching

Counselor Supervision

EMDR Consultation (for therapists)

I understand that all therapy services are virtual and only available to adults in Ohio. *

Sea Glass only offers virtual therapy. All services are provided to adults in Ohio via telehealth. I need to be physically located in Ohio for my appointments.

Yes

I understand that Sea Glass does NOT accept insurance. *

Sea Glass does not accept insurance and cannot bill my insurance company directly.

Yes