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Client Service Request Form
Mahalo and congratulations on taking your first step toward improving your lived experience!
Please provide us with the following information and we'll do our best to respond within 24-48 hours.
If you don't hear from us within that time frame, please feel free to email Welcome@ElementalGuidance.com or call (808) 657-5507.
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* Indicates required question
Email
*
Your email
Is it ok to email?
Yes
No
Other:
Clear selection
Legal Name(s) of those seeking services:
Your answer
For the primary client (the person responsible for billing):
~
Best contact phone number
Your answer
If seeking couple therapy, please provide your partner's:
~Legal (first and last) name
~Best contact phone number
~An email for sending them EGLLC notices
~Date of Birth
Your answer
Just to be clear, Elemental Guidance's services are provided completely through audio/video telehealth (i.e., videoconferencing) by providers residing in Hawai'i. By checking below, you acknowledge being aware of this.
Got it! Can't wait! How do we get started?!
I'm on the fence about telehealth, but willing to give it a try.
Nevermind. I wanted to see someone in-person.
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