Your Information/Information Please

Below, please give a summary of what brings you to counseling today, and what you'd like to accomplish. This is confidential between you and your counselor or coach. 

Questions or concerns? Please let us know and we'll get back to you as soon as possible

By checking the box below I (client) agree and understand that:

  • My counselor will keep my information in complete confidence

  • All appointments and copays will be paid in advance

  • Therapy and TeleTherapy sessions are for personal therapy only and these sessions/records will not be used for obtaining Disability Benefits, Social Security benefits, or for court cases

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