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Tranquil Wellness

Get Help

Name of person completing form

First name*

Last name*

Name of potential patient

First name*

Last name*

Preferred pronouns*

Phone*

Date of birth*

Month

Day

Year

Do you have a policy administered by Medicare or Medicaid?

What services are you interested in?*

Cognitive Behavioral Therapy (CBT)

Dialectical Behavioral Therapy (DBT)

Trauma-Informed Care

Mindfulness-Based Practices

Person-Centered Therapy

Exposure and Response Prevention (ERP) for OCD

Eye Movement Desensitization and Reprocessing (EMDR)

Other

Preferred location*

MA Office

RI Office

Virtual consultation

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