Request for Therapy/Counseling
We are honored that you are interested in seeking services with us at Indigenous Circle of Wellness. We invite you to complete this interest and request for therapy/counseling form. It is recommended that you visit our website at www.icowellness.com to become familiar with our practice, our providers, the services we offer, and our approach to wellness. 

Important note: We only provide therapy services to folks who are in the state of California. It's also important to let you know we currently have a waiting list to begin services. 

If you have any questions, concerns, or would like a list of other trusted providers, please email us at info@icowellness.com or call us at 626-782-5570 ext. 0.

Sign in to Google to save your progress. Learn more
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Indigenous Circle of Wellness, Inc.. Report Abuse