Telehealth · Texas · Mississippi · Louisiana · Washington

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🔒 HIPAA-compliant · Telehealth only · Insurance & cash pay · TX · MS · LA · WA

Personal Information

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth

City / State

Emergency Contact Name

Emergency Contact Phone

How did you hear about us?

Insurance & Program

Payment Type *

Insurance Cash Pay / Self-Pay Auto Injury (Lien-Based)

Insurance Provider

Member ID

Group Number

Program Type *

Individual Therapy (Telehealth) Auto-Injury Mental Health Therapy

Reason for Seeking Services

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Tell us about yourself

First Name *

Last Name *

Email Address *

Phone Number

License Type *

Primary State *

Current Employer / Practice

Supervision Hours Completed So Far

Target Licensure Completion Date

Tell us about your supervision goals *

You're all set!

Thank you for reaching out. Victoria Williams, LPCS will review your submission and contact you within 1–2 business days to discuss next steps.

In the meantime:

Check your email for a confirmation
If you have urgent needs, call 346-336-4667
For mental health crisis support, contact 988 Suicide & Crisis Lifeline by calling or texting 988