Mental Health Counseling Session

Mental Health Counseling Session
Legal Name*

First Legal NameLast Legal Name
Phone Number
Please enter a valid phone number.
Valid Email Address*
Are you 18 years old or older?*

YesNo
If you are 17 years old and younger, a guardian needs to complete release of consent form. I can give these forms to you or have your guardian accompany you to the first appointment.
Roosevelt Campus
Vernal Campus
Do you want to meet via Zoom or in person?*

ZoomIn Person
Should be Empty: