Interest Form | Bamboo Center

Name(Required)

Email(Required)

Phone(Required)

If phone call, I give permission for Bamboo Center to leave a message:

Untitled(Required)

I am interested in (click hold shift on all that apply):(Required)

Age of child

(If for Youth Telehealth)

I would prefer to meet via (click hold shift on all that apply):(Required)

My Clinician preference is:(Required)

Dr. Anna Darbonne (Adults only)

Dr. Tracy Ellis

Dr. Erik Bjorndal (Adults only)

First Available

The Heart of the Matter(Required)

What is going on in your world right now, and what goals or shifts are you looking to achieve with our team?

Before we hop on a brief call together, let’s check our alignment on a few fit factors:(Required)

We are the right fit for your goals: I confirm that we are looking for specialized, forward-moving growth, grief, or relational care for stable individuals. I understand that Bamboo Center does not provide crisis intervention, acute behavioral management, active psychiatric crises, or participate in any legal proceedings, custody disputes, or court-mandated counseling.

We choose to keep our focus entirely on you: I understand that Bamboo Center operates exclusively as a private-pay, out-of-network practice to protect our unhurried time options and so that our care, files, and time remain entirely confidential, discrete, and free from insurance company restrictions. I am comfortable handling session investment fees out-of-pocket at the time we meet.

Our care travels seamlessly with your lifestyle: I understand that due to interstate licensing laws, our doctoral clinicians can work with us digitally as long as we are physically located within a PSYPACT-approved state at the exact time of our session.

Our primary home base and main travel destination states are selected below:(Required)

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