Contact us.selfmattersllc@gmail.com(937) 603-62557989 Washington Woods DrDayton, OH 45459 Please fill out the form below to help us better understand your needs. Name * First Name Last Name DOB * Date of Birth Email * Reason for visit * What is your reason for seeking therapy? Have you been in therapy before? Hospitalization * Have you recently been discharged from a mental health facility? Insurance * What insurance provider are you covered by? Availability * In a typical week what your availability for an appointment? Referal * How did you hear about us? Contact * What is a good number to reach you? (###) ### #### Thank you! We will be in touch shortly.
