Counseling Request Form and Fees
Please fill out the form below and select from the options provided.
Last Name
*
First Name
*
Phone number:
*
Street Address
*
City
*
State
*
Zip
*
Your Email Address
*
FEE SCALE:
OUT OF POCKET The first session covered with fee. The second attended session is FREE. The third & subsequent sessions are at a discounted rate. Sessions are one hour in length.
*
Initial Asessment (Add $65.00)
Individual (First Session) (Add $50.00)
Individual (Second Session)
Individual (Third Session) (Add $30.00)
Couple (First Session) (Add $60.00)
Couple (Second Session)
Couple (Third Session) (Add $45.00)
Family (First Session) (Add $75.00)
Family (Second Session)
Family (Third Session) (Add $55.00)
INSURANCE: Initial Assessment - $65/hour; Individual - $55/hour; Couple - $65/hour; Family - $75/hour
Total
$
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