Marriage Counseling & Family Therapy

Confidential Consult

IF YOU ARE SEEKING TO SCHEDULE AN APPOINTMENT, PLEASE COMPLETE

REQUEST AN APPOINTMENT

THE FOLLOWING FORM IS IF YOU ARE INTERESTED IN LEARNING MORE ABOUT SERVICES BUT NOT YET READY TO REQUEST AN APPOINTMENT.

Please fill out the following information to receive a free, email, preliminary consultation by a licensed mental health professional. This consultation is designed to help further clarify specific counseling needs, determine the appropriate type of counseling and answer any questions you may have prior to entering counseling.

This preliminary consultation is provided via email and confidential. Mental health professionals are bound by a code of ethics and legally responsible for maintaining confidentiality. While confidentiality is upheld, this consultation alone does not bind either party or represent entering into a therapeutic contract. You will be contacted within 48 hours by a licensed mental health professional.

Confidential Consultation

  • Please let us know how you heard about us.
  • We are participating providers with BCBS only. IF this is your carrier, we will check benefits & file directly for you. Should you have an alternate carrier, we require payment at time of service and will provide you with an invoice for you to submit to your carrier.

  • Presenting Problem

  • Please indicate all that apply, either historically or currently, to help us better assess which type of therapy will best meet your needs.
  • Please indicate if you have had previous counseling relating to this issue
  • Please identify if any of the following are currently active in your relationship.
  • This field is for validation purposes and should be left unchanged.