Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Terms & Conditions *

If you or someone you know is in immediate danger and/or experiencing a medical or mental health emergency, please call 911 or go to your nearest emergency room. By submitting this form, I consent to being contacted by Shoreline Therapy & Consulting or its authorized providers via phone, voicemail, or email. I agree to the processing of my personal health information, which may include protected health information (PHI). This information may be accessed by the licensed professionals of Shoreline Therapy & Consulting in accordance with HIPAA guidelines. For more information, please see our Privacy Policy.

I agree to the Terms & Conditions

Terms & Conditions for SMS Texting Services

By clicking this box, I consent to being contacted by Shoreline Therapy & Consulting or its authorized providers via text. Text messages from Shoreline Therapy & Consulting are conversational, human-to-human, and not automated. However, you can reply STOP to cancel. Message and data rates may apply. Message frequency may vary, based upon your needs. Support via SMS is available during business hours only. SMS is not for emergencies or crisis support. For HELP, call 911 or go to your nearest emergency room. For more information, please see our Privacy Policy and Terms and Conditions of SMS Texting Services.

I agree to the Terms & Conditions for SMS Texting Services