Live Chat 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 Schedule Your Live Chat Counseling
Sessions? Once A Week? Twice A Month?
Are You Looking For Day Time or Evening Time Sessions? Ideally What
Day or Days Would Match Your Schedule
Thank You For Your Therapy Request. A Clinical Supervisor Will Contact
You Via Email or Phone To Schedule Your Live Chat Session Answer Any
Additional Questions.
Live Chat eTherapy
Counseling Wellness Therapy
The Place To Get The Help You Need











Live Chat is the most inexpensive counseling session on the site: $55.00 for a 45 minute
session.

his method is ideal for individuals who are more text based and are able to express
themselves in the written word. You will be amazed at how quickly and easily you can express
your issues. Many therapists are now combining Live Chat with their face-to-face clients as
there are some issues clients are reluctant to discuss in a face-to-face-session.

To book a Live Chat eTherapy session you can fPAY FOR SESSION , then call
1-800-841-6296 to schedule a session.  Once you speak with the clinical coordinator, they
will walk you though how to sign on to your chat session.

Your counselor would like you to fill out the Chat Intake Form below prior to your session.