Individual Consultation

1

How did you first come in contact with us?* This field is required.

Google

Instagram

Referral

2

Which of the following best describes your current relationship status?* This field is required.Please tell us a little bit about yourself, so that we can better understand your situation

Single

Dating / Long Term Relationship / Engaged

Married

3

Can you tell us about yourself and what's making you seek guidance now?* This field is required.Please be as detailed and specific as possible

4

Describe any sexual concerns you may have.* This field is required.Please be as detailed and specific as possible

5

Thank you! Since we only have a limited number of spots available to work with new clients, what are you looking to achieve as we work together?* This field is required.Again, please be as detailed and specific as possible. What’s your vision or dream here? What would you define “success” as?

6

How ready are you to start therapy? Rate yourself from 2 (not really) to 10 (I'm ready to start yesterday!)* This field is required.

2

4

6

8

10

8

If using Insurance: List your ID number and insurance company phone number.* This field is required.List the name of your insurance company, ID number, and insurance company phone number.

9

Would you like to receive periodic emails from Next Stage Counseling & Wellness™ about growing your relationship with yourself and your partner?* This field is required.

Yes

Not at this time

10

Not Finished Yet... Last (And Most Important) Step! Please Confirm Your Contact Information Below, And Then Select A Time For A Consultation Call On Our Calendar* This field is required.STEP 1: Submit contact information below STEP 2: On the next page, PICK OUT A TIME that works with your schedule. STEP 3: We'll contact you almost immediately to confirm your time.

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