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Self-Pay Contact Form



All of my counseling sessions are Telehealth Only, no in-person sessions. So you will need access to the internet, your own phone for counselor to get in touch with you in case of technical difficulties, and your own email address where you can receive appointment reminders and document requests.*

Email Address*

Do you have any form of health insurance (Medicare, Medicaid, Health Insurance, etc)?*

Have you been court ordered for counseling services or was it recommended by your lawyer, Child Protective Services, or the Department of Social Services? *

Do you have current or pending legal issues?*

Have you had any recent Hospitalizations (due to mental health or substance abuse issues), In-Patient Counseling Services, or time served in jail/prison?*

Is there any certain day or time you would need services due to other obligations?*

How often were you planning to attending counseling services*

What issues/problems were you wanting to address in counseling services?*

What state do you currently reside in? *

By checking Yes I acknowledge and understand that not all issues/problems are appropriate for Telehealth mental health counseling services. If at any time my counselor feels I would benefit more from In-Person Counseling Sessions then I will be given referrals to other providers in the area. I understand that during the Initial Counseling Session the counselor and I will discuss my counseling goals/objectives and determine if Telehealth Counseling is appropriate for me and if the counselor is a good fit for my needs. *

Message (Optional)

Your form has been submitted! Please allow 3-5 business days for a response. Thanks!

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