Mayfield Counseling Centers
Your Name
First Name
Last Name
Leader who Provided Referral
First Name
Last Name
Therapy Options Available for Reimbursement
Individual Therapy
Divorce
Neurofeedback
Trauma
Anxiety
Depression
Grief
Disclaimer: Upon securing approval, I understand that Chick-fil-A will pay for the first two sessions of the listed Therapy Options above. I also understand that the heart of this offering is to help those who are currently experiencing a situation, not for proactive use.
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Scheduling & Attendance: It is your responsibility to schedule and attend your visit with the selected Therapist. Not attending your session will void your future ability to participate in this program and the session expense will be deducted from your next paycheck.
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Provide Email to complete Referral Request - This will be used to schedule sessions with Mayfield Counseling Centers.
example@example.com
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