Accelerated Trauma Program Request Form

Complete the form below to schedule a complimentary 10–15 minute consultation. We will answer your questions, discuss your goals, and help determine whether the Accelerated Trauma Recovery Program may be a good fit for your needs.

Our Physical Location: 13805 Village Mill Dr, Ste 201, Midlothian, VA 23112

We also provide secure virtual services throughout Virginia.

Accelerated Intensive Request Form

Subscribe

First Name

Last Name

Email

Phone/Mobile

Who is seeking services?

Do you prefer in-person (Midlothian Office) or virtual program?

What concerns would you like to address? (Select all that apply)

Trauma / PTSD

Childhood Emotional Wounds

Anxiety

Panic Attacks

Grief & Loss

Military or First Responder Experiences

Other

Anything you would like us to know before contacting you?

I understand that submitting this form does not establish a therapeutic relationship and does not guarantee acceptance into the Accelerated Trauma Recovery Program.

I understand that participation requires completion of an assessment and determination that the program is clinically appropriate for my needs.

I understand that the Accelerated Trauma Recovery Program is a private-pay service with program investment beginning at $2,995 and is not billed directly to insurance.