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Living Water Counseling Ministry- Virginia and North Carolina Telehealth Counseling

Mental Health Counseling, Christian Counseling, Substance Abuse Counseling

" ...If you knew the Gift of God...you would have asked of Him, and He would have given you Living Water." (John 4:10 KJV)

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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.

I will be out of the office Monday, November 20, 2023 through Sunday, November 26, 2023 for the holiday.

Name*

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.*

Yes I understand all services are telehealth only and I have access to the internet, a personal email address, and a personal phone where I can be reached in the case of technical difficulties.

No I cannot meet all of these requirements

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? *

Yes

No

Do you have current or pending legal issues?*

Yes

No

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

Yes

No

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. *

Yes, I understand

No I do not understand

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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