What type of support are you seeking?
*
Please Select
Individual Therapy
Couples or Marriage Counseling
Family Therapy
Group Sessions
Other
Please select any specific concerns you'd like to address
*
Please Select
Anxiety
Depression
Trauma
Grief
Stress Management
Relationship Issues
Other
Do you prefer sessions in English or Spanish?
*
Please Select
English
Spanish
No Preference
No tenemos proveedores que hablen español
Which session format do you prefer?
*
Please Select
In-Person
Telehealth
No Preference
Do you have insurance you'd like to use?
*
Please Select
Yes - Please specify
No
Not Sure
Private Pay
What days and times are you generally available?
*
Would you be interested in learning more about a Masters Level Counselor Intern OR Resident?
*
Please Select
Yes - Masters Intern
Yes - LPC Associate
No
Not Sure
I would like to learn more
Low-Cost/Affordable Options ($15-30/session)
Would you be interested in learning about our FREE Support Group?
*
Please Select
Yes
No
Not Sure
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Is there anything else you'd like us to know?
What type of counselor are you looking for?
Should be Empty: