Consultation Form

Name *
Phone *
Name of Spouse (or child)
Name of Spouse (or child)
Privacy and Security *
I understand that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information I include in an email can be intercepted and read by other parties besides the person to whom it is addressed. I also understand that Amy Standifer will coordinate our initial phone consult after I've scheduled it through Simple Practice. I give her permission to leave me a message at the phone number and email address provided.

Amy Standifer MA, LPC
Owner / Therapist

Nancy Wilkins - Headshot.jpg

Nancy Wilkins MA, LPC-Intern
Supervised by
Scott Floyd, Ph. D., LPC-S, LMFT