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First Name

Last Name

Partner's Name (if interested in couple's therapy)

Phone Number

Zip Code

Please contact me via

Phone

I am interested in: select as many as apply

Couples Therapy

Individual Therapy

Group Therapy

Other

Days that work best for you Please note that not all may be available

Monday

Tuesday

Wednesday

Thursday

Friday

Times you are available

Morning

Afternoon

Evening

Comments

Please note the following:
1000 Hills Counseling & Consulting is an all online counseling practice. We do not provide any face-to-face services. If you are unsure if online counseling is the right fit for you, the free consultation is a great time to try it out.

Individuals are limited to one free consultation. If you cancel your consultation with less than 24 hours notice or no show your appointment, you will be charged for future consultations.

We do not currently accept any insurance or participate in any EAPs. All fees are due in full at the time of service. We do have a limited number of OpenPath slots available to clients who need a reduced fee. Please ask the therapist for more information.

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