Request edit access
Affordable Therapy Plan - New Client Appointment Request 
By entering your full name, email address, and phone number below, you are providing personal information that will be used by Larneka Lavalais, LPC PLLC for the sole purpose of responding to your request. We will only use this information to contact you to schedule your appointment.
Sign in to Google to save your progress. Learn more
Email *
I agree I am not in danger at this time and would like to request an appointment.

 *
If you are in serious or foreseeable danger, please call 911 or go to the nearest hospital.
***Please note: All appointments are virtual at this time. Must be a resident of Texas***
Client Type *
Service Type *
Client First and Last Name *
Parent/Guardian Name (Minor only)
Client Email (For minor add Parent/Guardian Email) *
Phone Number *
Home Address *
✅ Client Acknowledgment & Consent

Please read carefully and confirm below:

I understand that the Affordable Therapy Access Plan is provided by graduate counseling interns under the supervision of a Licensed Professional Counselor Supervisor.

I understand that the first two sessions are free, and after that, I must choose a monthly plan ($25 for 2 sessions OR $50 for 4 sessions).

I understand the maximum number of sessions is 4 per month.

I understand that missed or canceled sessions may still count toward my monthly plan.

I understand this plan is designed for affordable access and may not replace specialized or long-term clinical care if needed.

 *
Availability for sessions. You are welcomed to select multiple slots of availability *
Required
Providers Participating in the Affordable Care Plan
Clear selection
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of lavalaislpc.com.

Does this form look suspicious? Report

Google Forms