Assessment 

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Please complete this confidential e-mail assessment

We need your information to become familiar with your situation.

Your name:
Your e-mail address:
Your age:
Your highest completed education level?
What is your current employment situation?
How many people live with you?
Their relationship to you?
Are you currently under the care of a physician?
If yes, explain?

Please describe the situation you would like to address with your counselor:

Please describe any physical symptoms you may be experiencing:

What is your local phone number?

What is your city and state?
Have you used our counseling service before?

Payment Information: Free initial 10 minute consult; ($60.00 Assessment Fee)

I will be paying with Credit Cards
My credit card account number is:
Expiration Date:
The name as it appears on the card:

My billing address is:

Click here if you are faxing or phoning in your payment information:

 
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