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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. 

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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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