(Secure Video or Phone)
Please note: At this time, all counseling and coaching sessions are being conducted exclusively by video (telemental health/telehealth). We will update this form to accommodate face to face therapy requests when they become available again.
I understand that I am submitting a request to engage in teletherapy with a clinician employed by Dynamic Counseling and Coaching Solutions, L.L.C. I understand that “teletherapy” includes consultation, treatment, transfer of medical data, emails, telephone conversations and education using interactive audio, video, or data communications. I understand that teletherapy also involves the communication of my medical/mental information, both orally and visually.
Your information will be encrypted.