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Consultation Booking Request
Center for Creative Counseling Professional Consultation Services
:
Please complete the form below to request professional consultation services through the Center for Creative Counseling.
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Email
*
Your email
CONTACT INFORMATION
Name
*
Your answer
Company/Agency (if applicable)
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
Do You Consent to Receive Text Communication?
*
Yes
No, thanks. I prefer email.
Do You Consent to Receive the Center for Creative Counseling email newsletter?
*
Yes
No, thanks.
Job Title/Professional Role
*
Your answer
CONSULTATION REQUEST DETAILS
Type of Consultation Requested
*
Case Consultation
Art Therapy Consultation
Grief and Loss Consultation
Parenting Consultation
Private Practice Consultation
Other:
Required
Preferred Consultation
Format
*
Please select your preferred format for the consultation meeting(s).
Video Meeting (HIPAA-compliant platform)
In Person Meeting (Client responsible for providing confidential office space)
Phone Consultation (Must be approved by consultant)
Other:
Required
Preferred Consultation
Frequency
*
Please select all that apply.
One-Time Consultation
Multiple Scheduled Consultations
Weekly Consultations for Specified Timeframe
Bi-Weekly Consultations for Specified Timeframe
Monthly Consultations for Specified Timeframe
Not sure at this time.
Other:
Required
Preferred Consultation
Duration
*
Please choose your preference for the duration of each consultation meeting.
1 Hour Blocks
2 Hour Blocks
Required
Your Availability
*
Please identify your preferred consultation times. Check all that apply. [NOTE: The timeframes offered below are based on consultant availability.]
Monday Morning [between 9am-12pm]
Monday Afternoon [between 12pm-3pm]
Tuesday Morning [9am-10am]
Friday Morning [9am-10am]
Friday Afternoon [1pm-3pm]
None of these times will work and I would like to discuss other options.
Other:
Required
Additional Services Requested
*
Would you like to add any other services or products to your consultation package?
[NOTE: Additional services incur additional fees.]
Recommendations Report
Consultation Summary
Letter of Recommendation
Letter of Summary
Meeting Attendance
Documentation/Videotape Review
Supplemental Materials/Tools/Resources for Purchase
Not Sure at This Time
I Don't Require Additional Services
Other:
Required
CONSULTATION NEEDS
Please describe your consultation needs below.
*
What do you need support with?
What do you hope to gain from the professional consultation process?
What are your consultation questions?
NOTE: Please do not include Protected Health Information in this request.
Your answer
THANK YOU FOR YOUR REQUEST - CLICK SUBMIT BELOW.
Once you're booking request is received, someone from the Center for Creative Counseling will reach out to the email address provided within 48 hours to discuss scheduling and consultation package options with you. Thank you!
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