Name *

First Name

Last Name

Phone (optional)

(###)

###

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I'm inquiring about *

Psychotherapy

Speaking Event

Breathwork / Yoga

General Inquiry

Session Preference (if requesting therapy)

In-Person Sessions

Online Sessions

No Preference

Referral Option (if seeking psychotherapy)

If Jeff's caseload is full, can he CC you in an email to introduce you to another therapist on the Shepherd Psychotherapy team who is accepting new clients?

Sure 👍

No thank you ✌️