Clone of Immigration Evaluation Query Form

1

Name* This field is required.

First Name

Last Name

2

E-mail* This field is required.

example@example.com

3

Phone Number* This field is required.

4

Select the type of counseling services you are inquiring about* This field is required.

One-on-one (individual)

EMDR Therapy

Couples & Family

Teen Counseling

Christian Counseling

ESA Evaluation

Other

5

What is your preferred counseling location?* This field is required.

Sugar Land Office

Katy Office

Telehealth / Online

6

Are you physically located in either Texas or North Carolina?

Yes

No

7

What type of accommodation are you requesting documentation for?* This field is required.

Apartment Housing

Rental Home

College Dormitory

Other

8

For Other Accommodation type, please provide details* This field is required.

9

ESA Detail Information* This field is required.Enter details for each ESA; select how each helps you (Helps Me By should be different for each one). Note that the therapist will be conducting a thorough evaluation to determine whether you truly qualify for each ESA.

10

Please tell us a little about what brings you to counseling and how we may be able to help.* This field is required.It can be just a brief description

11

How soon would you like to schedule an appointment, and do you have any preferred days or times?* This field is required.In some cases we can do same-day or next-day appointments

12

Do You Have Any Preferences, Scheduling Needs, Insurance Requirements, or Therapist Requests?* This field is required.Please let us know if you have preferences related to therapist, therapist style, specialization, availability, telehealth vs. in-person sessions, insurance, scheduling, language needs, or any other important considerations.