Email Therapy Intake Form
All Fields Required
Your name:
Email:
Street
Address:
City:
Zip Code:
State:
Phone:
Name & Phone Number Of Emergency
Contact:
Best Time
To Call You:
What Are Your Presenting Problem or Focus For Counseling?
What Are Your Previous Counseling Experiences?
Are You Currently Having Any Symptoms And How Severe Would You
Describe Them
?
How Often Would You Like To Receive Email therapy? You May Choose
One Session at a Fee of $45.00, or Unlimited Email Therapy For The
Month at $195.00
Would You Prefer a Male or Female Therapist?
Thank You For Your Therapy Request. A Clinical Supervisor Will Contact
You Via Email or Phone To Schedule Your Email Therapy session(s).
Counseling Wellness Therapy
The Place To Get The Help You Need
