Counseling Request Form with Vanessa Fox, Resident Counselor

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Please read the information HERE to learn more about counseling with Vanessa. There you can find her bio, rates, breakdown of services, and other frequently asked questions.

I am applying for counseling for... *

myself

someone else

myself and others (family or couple session)

If you are applying for counseling on behalf of someone else, what is your name and relation to the client?

Client's First Name: *

Client's Last Name: *

Client’s Birthdate: *

YYYY

If you are requesting couple or family counseling, please list names and birthdates of all others who will attend counseling.

Contact Email: *

This email will be used to send you a sign up link for our patient portal (scheduling, documentation, billing, etc.).

Phone Number: *

Please enter a phone number where the counselor can contact about scheduling an appointment with the client.

Are you comfortable receiving voicemails at this number? *

I am comfortable receiving voicemails.

I do NOT want to receive voicemails.

Secondary Phone Number:

You may enter a secondary phone number where the counselor can contact you.

What way(s) would you like the counselor to contact you? (check all that apply) *

Text message

Phone call

Required

What type of counseling services are being requested?
*

Individual Adult counseling

Individual Child/Teen counseling

Couples/Pre-marital counseling

Family counseling

Would you like to attend counseling in-person or over virtual telehealth?
*

In-person counseling is conducted at Hyland Heights Counseling Center,

located at 82 English Tavern Rd., Rustburg, VA 24588 (on the HHBC campus).

*For telehealth, note that the counselor can only see clients residing in Virginia (or with a temporary VA residence for school, etc.).

In-person

Telehealth

A mix of both/ not sure

Please briefly describe your interest in seeking counseling at this time: *

I understand that this form is an application for *paid* counseling with a Licensed Resident and that the 50 min session cost is $50. *

Yes, I understand.

No, I was looking for free counseling services with an intern counselor.

Due to licensing laws, you will need to be physically in the state of Virginia when meeting with your counselor (even if meeting virtually). *

I understand and confirm that I am in Virginia.

I do not live in Virginia or reside here temporarily.

How did you find out about our counseling services? *

Hyland Heights Baptist Church

PsychologyToday profile

Google/internet search

Someone I know recommended it to me

I was referred here by another healthcare professional

Other:

Any additional comments/ questions:

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