Counseling Inquiry

Counseling Consultation Form

Cindy Gullo, LCPC
Name of the Individual Completing Form*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Age*
I work with high school teen girls and women in their 20s and 30s, not with men or younger girls.
Myself15-17 year old daughter
Daughter/Client's Name *

First NameLast Name
Daughter's Email*
example@example.com
Daughter's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Daughter's Age*
What's been going on that you're reaching out to today? *
GooglePhysicianFriend/FamilyOther
My fee is $210 for a 50-minute session.

Most clients attend weekly sessions for about 12 to 15 weeks before shifting to 1–2 sessions per month. Therapy isn’t forever — the goal is meaningful progress, not a lifelong subscription.

I’m not in-network with any insurance panels, but many clients use their out-of-network benefits to get partial reimbursement. You can check with your provider to see what your plan may cover.
I Consent
Once the form is submitted, you'll be redirected to IntakeQ to schedule a 15-minute video consultation.
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Counseling Consultation Form