Free Consultation Request Form
Thank you for contacting us. 

* Please kindly note that we have a waiting list at this moment, and there would be no availability until June 2024.

Please complete this confidential form to request a 15-20 minutes Free Consultation. We will contact you within 1-3 business days with our earliest availability to schedule a meeting. 

If you are currently experiencing a crisis or in an emergency situation, please do not use this form; instead, pleae call 24/7 Crisis Line "988" or "1-866-427-4747."

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Email *
Typle of Counseling/Therapy you are seeking: *
Required
What days/times would it be convenient for you? Please lsit as many options as you can.  
* Please kindly note that we have a long waiting list at this moment, and there would be no availability until June 2024. *
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
What is your time zone? (Pacific, Central, Eastern, Japan, etc.) *
Would you prefer a Phone Call or Online Video meeting? *
Full Name *
Email Address *
Phone Number (We will reach out to you by email, and we will not call you unless you request us to do so) *
Any specific questions or concerns you may have?
Please note that this meeting is not a counseling service, and CCC Counseling & Consulting or our providers are unable to guarantee to schedule a free consultation or counseling appointments depending on the availability and/or scope of service(s). *
Thank you for your inquiry. You will receive an email from appointment@cccplace.com within 1-3 business days, and we encourage you to add this email address to your contact list. 
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