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Counseling Inquiry Form
Please note, if this is an emergency situation, refer to our crisis resources, linked
here
.
First Name
Last Name
Email
Cell Phone
Birth Date
Availability
Membership Status
Non Member/non-regular attender
Member/Regular attender
Type of Service
Individual Counseling
Family Counseling
Couples Counseling
Parent Consultation
Premarital Counseling
ADHD Assessment
EMDR Therapy
Play Therapy
Peferred Method of Contact
Email
Phone
Insurance Self Reimbursement
Yes
No
While we do not submit health insurance, we provide medically coded receipts for clients who wish to file for reimbursement with their insurance company. If you plan to submit a Superbill to insurance for self reimbursement, please indicate when you inquire about counseling so we can refer you to a counselor whose license will be accepted by insurance.
Financial Assistance Request
Yes
No
Our counseling fees range from $65- $135 per session. If you are unable to pay this fee, please request our Scholarship Application. We have limited scholarship funds to offer based on an income sliding scale rate. A scholarship application does not guarantee a reduced fee. Additionally, practicum counselors are available to see individuals at a reduced rate.
Reason for seeking counseling
Submit