Consultation Questionnaire 
Someone from our office will be in contact with you within 24 hours after your form is submitted if you are deemed a good fit for the services we offer. 

Note: We do not accept any insurance. 

Fees: 
Individual Counseling $150 (50 minute session)
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First Name *
Last Name *
How did you hear about us? *
Telephone Number *
Can we text and/or voice message you to the above telephone number? *
Email Address (Note: We will not be able to contact you if we are not allowed to email you. Our telehealth systems require email availability.) *
Can we send you emails to the above address? *
Is the person requesting therapy in the state of Texas? *
Is the person requesting therapy services at least 21 years of age? *
What type of therapy services are you seeking? *
Required
Which of the following best describes the issue you are experiencing? *
Required
Briefly describe the issue that is causing you to seek therapy? *
We only offer virtual therapy services. Are you okay with recieving therapy virtually? *
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