1. Prepay for session             2. Complete Intake Form
Telephone Counseling Intake Form
All Fields Required
Your name:
Email:
Street
Address:
City:
Zip Code:
State:
Phone:
First & Last Name of Emergency Contact:
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 Telephone 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 Telephone Session With You
And Answer Any Additional Questions.
The Place To Get The Help You Need
Welcome to our Telephone Counseling Page!

You have found a place where you can get the help you need right in your home or office. Phone
counseling is a powerful tool to help you get to the heart of your issues very quickly and easily. Our
therapists are trained to build rapport with you and create an environment of safety and counseling
experience. Our therapists are knowledgeable and can help you right now.

This is a service that charges a fee. Our fees are reasonable. Feel free to call 1-800-841-6296 to
discuss your counseling needs. Please fill out the intake form below so that we can begin. You
will then be sent a consent for treatment and our HIPAA forms.  We look forward to providing you
with the care you need today.

If you are suicidal please call a suicide hot line at -1-800-273-TALK.