Counseling Request Form and Fees
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  * 
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.  * 
INSURANCE: Initial Assessment - $65/hour; Individual - $55/hour; Couple - $65/hour; Family - $75/hour
Total $
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