Request Appointment

All of our services are virtual. We do not accept insurance.

If you are in crisis, please do not use this form - instead call 911, 988, or go to your nearest emergency room. We are unable to respond to urgent requests or emergencies. We will respond to your request within two business days. Thank you for considering Sea Glass!

Name

First Name

Last Name

Phone

(###)

###

####

Who are you seeking therapy for?

Individual therapy for myself

Couples/sex therapy for me and my partner

What type of services are you interested in?

Preferred appointment time:

I'd like to work with:

Did someone refer you to us?

If applicable, please list the provider or practice that referred you.

Message

What else would you like for us to know?

I understand that:

Sea Glass clinicians are only licensed in Ohio and I need to be physically located in Ohio at the time of service. Sea Glass does not accept insurance and cannot bill my insurance company directly. Sea Glass only offers virtual therapy and that all services are provided to adults in Ohio via telehealth.

Yes

More ways to contact us

Snail Mail: Sea Glass Counseling and Consultation
545 Metro Place S, Suite 100, Dublin, OH 43017

Fax: Sea Glass does NOT utilize faxing. Please send any materials needing faxed to our HIPAA-compliant email: hello@seaglassohio.com