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Self-Pay Contact Form

Note: I am not providing Marriage/Couples Counseling at this time. I only provide Individual Counseling to Adults 18 yrs and up.

***If you have not received confirmation that this form was received by email in 3-5 business days please resubmit the form as it likely was not received***

Client Name*

Client Gender*

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?* (Current appointment hours are Monday-Thursday 10:00 am-5:30 pm. I am closed Friday, Saturday, and Sunday) 

How often were you planning to attending counseling services* (Once per week, Twice a Month, Once a month, Unsure, etc)

What issues/problems were you wanting to address in counseling services?* (Anxiety, Depression, Grief/Loss, etc)

What state do you currently reside in? * (Counselor is only licensed to practice Telehealth in Virginia and North Carolina)

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!

Living Water Counseling Ministry. Telehealth Services. Virginia & North Carolina. Christian Counseling. Substance Abuse Treatment. Mental Health Psychotherapy. Individual Services. Anxiety. Depression. Panic Attacks. Seasonal Affective. Grief/Loss. Spirituality. Women's Issue., Addiction. Alcohol Use. Bipolar Disorder. Career Counseling. Coping Skills. Drug Abuse. Dual Diagnosis. Emotional Disturbance. Infertility. Mood Disorders. Pregnancy, Prenatal, Postpartum, Self-esteem. Stress. Life Coach.
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