Crisis Counseling Appointment Request

1
Are you a current client of Joel Daugherty, LPC-S?* This field is required.
YESNO
2
Are you currently suicidal or experiencing thoughts of self-harm?* This field is required.
YESNO
3
Name* This field is required.
First Name
Last Name
4
Phone number* This field is required.
Please enter a valid phone number.
5
Email* This field is required.
example@example.com
6
Requested appointment date* This field is required.Guaranteed booking is within 48 hours of request. Appointment may not be available the same day of request. Joel Daugherty, LPC-S does not conduct sessions on Friday afternoons, weekends, or during holidays.
Date
Month
Day
Year
7
What time would work best on your requested date?* This field is required.You may select mulitple times.
8:30 a.m.
12:30 p.m.
5:30 p.m.
8
Please briefly describe your need for crisis counseling.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
9
Crisis Counseling Session Fee* This field is required.Session fee is non-refundable and may not be applied to past or future session fees.
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ORDER SUMMARY
Total costUSD
Crisis Counseling Session$300 session fee + 3% online transaction fee.
$309.00Edit
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Total cost $0.00
10
Payment Methods
Debit Or Credit Card
Select PayPal Method
Choose from one of the PayPal options to make your payment.
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