Gates Counseling PLLC Consultation Request

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Please complete this form and we will be in touch via email to set up a free 15 min. consultation phone call. We try to respond to requests with in 48 business hours (business hours are Mon.-Thurs.). Please be aware that it is not uncommon for our emails go to your junk or SPAM folders so please keep an eye out for an email from rebecca@gatescounseling.net.

First Name *

Last Name *

E-Mail Address *

Phone Number *

Is it okay to text this phone number? *

Yes

I am interested in the following services *

Individual Counseling- using insurance

Individual Counseling- private pay

Counseling Intensive- EMDR and/or Somatic (Private pay only)

I am a Therapist seeking EMDR Individual and/or group consultation

Required

State of Residency *

Is there anything you would like to share with me prior to our conversation? *

Submit

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