I am currently experiencing (select all that apply)...

Panic Attacks

Anxious Worry

Feeling On Edge

Other

I am currently seeking (select all that apply)...

How would you rate your current distress level?

High

Moderate

Low

Have you ever worked with a counselor before?

Yes

No

What would you like to get out of your call (select all that apply)?

How would you rate your current financial status?

Good

Fair

Poor

If we both decide counseling is a good fit, how would you prefer to cover the cost of sessions?

I'd prefer to pay out of pocket.

I'd prefer to use my insurance.

Let's discuss on the call.

Unfortunately, we do not work with your insurance. Would you like a low cost alternative?

Yes

No

How can we best contact you?