Your name: Your e-mail address: Your age: Your highest completed education level? high school graduatehaven't completed high schoolsome collegecollege graduategraduate schoolWhat is your current employment situation? employed part-timeemployed full-timeunemployed-not by choiceunemployed-by choiceretiredstudentat-home parentHow many people live with you? I live alone1234567Their relationship to you? Are you currently under the care of a physician? YesNoIf 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? YesNo
Payment Information: Free initial 10 minute consult; ($60.00 Assessment Fee)
I will be paying with MastercardVisa My credit card account number is: Expiration Date: JanFebMarAprMayJunJulAugSepOctNovDec 20082009201020112012The name as it appears on the card:
My billing address is:
Click here if you are faxing or phoning in your payment information: