Appointment Request Form

Please tell me what day of the week and time of day you prefer.

Please correct the errors described below.

Please complete the form below and we will reach out to you within 24-48 hours to answer your questions or to help you schedule your first appointment.

Counseling for Adults 18+ only.
Phone Consultations are 10-15 mins in length
If you are attending couples, please provide your partners full name, DOB, email & phone here.

If you are having a mental health crisis please call 911 or go to the emergency room. This form is not to be used for a crisis.

Save our phone number in your cell phone so that you will know when I will call. 325-261-8360 - Elizabeth

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