Online & Telephone Counseling Request Form

Please fill in the form below and submit it to us. Please be as thorough as possible, providing as many facts, history and details of your situation that you feel are pertinent. Our counselor will either call you or e-mail you a reply (depending on your preferences). She will then, once you have chosen to be counseled, spend one hour, reviewing your submission and other information derived from the initial contact, and begin the counseling process. After our FREE initial e-mail consultation, subsequent e-mail consultations are $35 for each session. E-mail sessions consist of a question by you and an e-mail reply by the counselor. Telephone sessions are one hour in length, after the initial 15 minute FREE phone consultation. Subsequent phone consultations are $60/hr. Thank you.
What is your name?

What is your phone number?

E-mail address?

How do you wish to be contacted?
By phone only By e-mail only By e-mail or phone
Enter todays date?
Please check all the boxes which describe your current situation.
Married Engaged Divorced Single Single Parent House wife/husband Career Person Student
Which condition BEST describes your situation?
Depressed/Sad Bitter/Resentful Angry/Hateful Desperate/Confused Hopeless Guilt/Shame
What age range are you?
What age range is the person in question?
What religion, if any, are you?
What religion, if any, is the person in question?
What lifestyle do you, and/or the person in question, prefer?
Enter any and all thoughts, concerns, feelings, hopes, dreams, doubts, and visions you may have that can help us understand your situation better. There is no limit, so please be thorough and fully inclusive of all related information.

CALL FOR FAST, PERSONAL SERVICE: 808-357-1171