Interest Form

Active and Connected Family Therapy Client Care Coordinators are available Monday through Friday 9:00 am to 5:00pm Eastern Time to answer any questions or help schedule an appointment with a therapist.  Call us at (434) 202-4080. 

You can also complete the contact form below and we will get back to you the next business day.

"*" indicates required fields

Client Name if different from person completing this form
Preference for In-person or Telehealth. Please complete the following questions if you are interested in therapy.
I understand that all therapists and providers at Active & Connected Family Therapy are out of network providers and I agree to pay out of pocket for treatment.*