Let’s Connect!

Your Name *

First Name

Last Name

Phone *

(###)

###

####

How do you prefer to be contacted? *

Email

Phone

Where are you located? *

Due to licensing regulations, I am only able to work with individuals who are located in Colorado or Michigan.

Colorado

Michigan

I am inquiring about individual counseling for: *

Myself

My teen

Do you have a time of day that you prefer to meet? *

check all that apply

Morning

Lunchtime

Afternoon

Evening

I'm flexible / No preference

*

By checking this box, you agree to receive text messages at the provided number from Jeannette Smith, LCSW. Message frequency varies, and standard message and data rates may apply. You have the right to OPT-OUT receiving messages at any time. To OPT-OUT, reply "STOP" to any text message you receive from us. Reply HELP for assistance.