June 29:11 Family Counseling Form

29:11 Family Counseling

Session Reservation
Parents may sign up for counseling (individual or family) with Dr. DeShannon Quiett-Burrell. Choose a date and time for your visit. Fill in the details of the family members attending.

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Reminder: 29:11 will pay for half the cost of counseling. The parent pays the remainder with this sign-up. The parent's cost for an initial 2-hour session is $85. The parent's cost for any subsequent session is $42.50.

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Dr. DeShannon Quiett-Burrell's Office

13128 Plank Road

Baton Rouge, LA 70714
Parent Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Family Members attending (Choose all that apply)
Session Type
Is this your family's first session with Dr. Quiett-Burrell?
Appointment
Payment Methods
Should be Empty: