Peyton Baldinger Consult Form
Let us know how I can help you!
Where are you looking to attend sessions?
In Person: Gold River, CA
Online (California)
What type of therapy are you looking for?
Individual
EMDR Therapy
Couple's Therapy
Family Therapy
Back
Next
Client Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Back
Next
Partner's Name
*
First Name
Last Name
Partner's Phone Number
*
Please enter a valid phone number.
Partner's Email
*
example@example.com
Back
Next
Availability
*
Monday
Tuesday
Wednesday
Thursday
Times
*
Mornings (8 AM - 12 PM)
Afternoons (12 PM - 4 PM)
Evenings (5 PM- 8 PM)
How did you hear about Freedom Counseling Group?
AI Search or Assistant
Google Search
Therapist Director
Professional Referral (Doctor, Psychiatrist or other therapist)
Personal Referral (Friend, Family or Colleague)
Social Media
Other
Is there anything else we forgot to ask?
Let us know if there is any other information that would be helpful for us to be aware of as we match you. Please note we will need full names and email addresses for each potential participant if you are looking to participate in family or couples counseling.
Please verify that you are human
*
Submit
Should be Empty: