Request An Appointment

Our greatest glory is not in never falling, but in rising every time we fall.

Please complete the form below to request an appointment. We will try to accommodate your request and will be in touch as soon as possible.

First Name

Last Name

Phone

Preferred Date

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Message

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 Entwine Counseling Services harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.