Inquiry Form
Thanks for reaching out!

Please fill out this form to help determine availability and to help me provide appropriate referrals if necessary. I make every effort to respond within 3-5 business days.

*Please note that I do not have availability for new clients at this time.*
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Email *
Name: *
Phone number: *
How would you like to receive a response? Check your preference(s). (By checking a box, you give permission for receiving that form of communication.)
For whom are you seeking counseling services? (Please note that I work individually with adults; I am unable to accommodate requests for couples, family, or children's counseling at this time.) *
What is your age?
What are you hoping to address in counseling? (Please be as specific as possible.) *
Who recommended counseling? *
How did you hear about Undivided Soul Counseling? *
How would your sessions be covered? Check any that apply. *
What is your scheduling availability? *
What is your preference for sessions?
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If I am unavailable to schedule with you, would you like to be provided with information about other possible providers? *
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