Confidential Interest Counseling Form
We are SO excited you are taking this step. We would love to learn a little more about you before we get started. Please complete this interest form.  All of the information submitted is confidential and will only be seen by the Life Interconnected team for the purpose of determining if our services would be a good fit.  

Submitting an interest form does not guarantee acceptance as a counseling client.  If you are having an immediate or urgent concern or crisis, please call 911.  If you have any issues with the form or follow-up questions, you may contact us at hello@lifeinterconnected.com.  We will do our best to respond to your inquiry within one week.  
                                                                                            
                                                                                                Sincerely,
                                                                                                Amber Todd, M.S.
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Email *
Hello, what is your name? *
What is your phone number? *
What City and State do you live in? *

We do not accept insurance at this time, cash/credit card only. The rate for a 60 minute session is $140.

*
What brings you to counseling at this time? *
How did you hear about us?
What is your availability for counseling? Which days work best? Morning, Afternoon or Evening? *
Are you seeking virtual or in person therapy? *
What is the urgency of your counseling needs? *
Which of the following categories apply to you? (Check all that apply)
Would you like to be added to Amber's email list to receive her monthly newsletter, including info about workshops, counseling groups and new podcast episodes? *
How did you hear about Life Interconnected or Amber Todd?
Do you have any other questions for us?
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