Let's Connect.
Welcome! If you want to get in touch with Vienna Pae Cornell / Deep Well Counseling, you're in the right place.

Please take a moment and complete the following form. (Your responses are confidential and stored according to HIPAA guidelines.)

Once you click the "Submit" button, you'll be provided the link to our secure online portal to schedule a complimentary initial consultation. If you choose not to schedule through our online portal, I'll get back to you directly within 3 business days.

My practice is not equipped to see clients who need care coordination with multiple providers or are seeking specialized treatment in the areas listed below. Please do not fill out this form if you want treatment for any of the following:

- persistent self-harm/suicidal/homicidal thoughts and urges
- disordered eating
- couples therapy
- sex therapy
- separation/mediation therapy
- domestic violence
- Emotional support animal evaluation

Thank you for understanding.
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First Name:
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Last Name:
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Email:
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Phone:
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State:
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How did you hear about Deep Well Counseling?
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Are you looking for virtual or in-person appointments?
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How do you want to cover the cost of therapy? Please note: I don't accept ANY insurances other than those listed below. *
Is your insurance Medicare or Medicaid? If so, we would not be a good fit at this time. *
Do you have secondary insurance?
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Are you flexible with scheduling? At this time I have no availability outside of Tuesdays-Fridays, 9am-5:30pm Central Time, so I'd just like to make sure I could accommodate your scheduling needs. If you need weekend, evening, or Monday availability, we would not be a good fit at this time. *
What is your next step?
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If you'd rather be contacted directly and not schedule a consultation call through our online portal, how do you prefer to be contacted?
Please carefully read and acknowledge the following:
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Is there anything you'd like me to know?
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