Secure Contact Form

Quarternote Counseling, LLC

Thank you for contacting Quarternote Counseling. If you are experiencing a psychiatric emergency and/or are at risk of harming yourself and/or others, please do not use this form. Instead, please call 911, visit your nearest emergency room, or contact the Suicide & Crisis Lifeline by calling or texting 988.

Thank you for contacting Quarternote Counseling and your interest in receiving professional training and/or supervision services from our practice's owner and Clinical Director, Gillian Clissold, LPC.

Please bear in mind that, because Ms. Clissold is a Licensed Professional Counselor, she is unable to provide clinical supervision towards licensure to supervisees in Clinical Social Work.

Please be aware that Ms. Clissold's availability for trainings and/or supervision services varies. Submission of this form does not obligate you to receive trainings and/or supervision services from Ms. Clissold, nor does it guarantee that she will be available or able to provide these services to you. This form is to express your interest only.

Please complete and submit this form. Your submission will be encrypted and secure. Fields with a red asterisk (*) are required. You will receive a response within 5 business days.

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Your full name (first and last)

Type of license or residency

E.g., LPC, Resident in Counseling, etc.

Your email address

Phone number

Which is your preferred method of contact?

Email Phone No preference

Between what hours may we call you?

Please indicate which specialized service(s) you are interested in (please check all that apply)

Clinical supervision towards licensure

Training

Consultation services

How would you prefer to receive this service?

In-person Online No preference

On what day(s) might you be available? (Please check all that apply)

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

What time of day is preferred? (Please check all that apply)

Mornings (8am-12pm)

Afternoons (12pm-5pm)

Evenings (5pm-7pm)

Please briefly describe the reason for your interest in receiving specialized services from Ms. Clissold and in what, if any, specific topics or areas you are interested in receiving training/consultation? If you are seeking supervision services please let us know how far into your residency you are, what your areas of interest are (if any) and if you are currently receiving supervision from another professional.

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