Wait List Request
After you fill out this request, we will add you to Ms. Gallón's waitlist for counseling services. Generally speaking, her waitlist is two to three months.  Please be advised availability is subject to current client spots and there is no guarantee of a timeframe.  You may be contacted sooner than two months or a longer timeframe. If you would like to follow-up regarding your request you can contact us at info@hopeishere.co 
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Are you a new or previous client? *
First Name *
Last Name *
Phone number

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E-mail *
Preferred contact method *
Required
Do you plan on using insurance for services? *
If using insurance, what insurance do you have?
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Generally speaking what you are looking to address in counseling (ex. anxiety, grief, depression, etc.)? We want to make sure that your concerns can be addressed.  *
How did you hear about us?
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Required
Are you interested in being contacted for upcoming events or other services?
 *
While Esperanza might not always be available for individual counseling, she does sometime offer classes, groups and workshops to improve mental and emotional health. Let us know if you would like additional information.
Any additional comments or questions?
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