First Last Name *

First Name

Last Name

Phone Number *

(###)

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Counseling Service *

Please check the counseling service(s) you are inquiring about at this time.

Individual Counseling

Couples Counseling

Sports Performance Counseling

Would you like to use insurance? *

Yes, I would like to bill through insurance

No, I would like to pay out-of-pocket

I am unsure/undecided

Availability (Days of the Week) *

Please check all of the days you are available to meet with a counselor?

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays