Client Service Request Form

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Mahalo and congratulations on taking your first step toward improving your lived experience!

Please provide us with the following information and we'll do our best to respond within 24-48 hours.

If you don't hear from us within that time frame, please feel free to email Welcome@ElementalGuidance.com or call (808) 657-5507.

Email *

Is it ok to email?

Yes

Other:

Clear selection

Legal Name(s) of those seeking services:

~Best contact phone number

For the primary client (the person responsible for billing):

If seeking couple therapy, please provide your partner's:

~Legal (first and last) name

~Best contact phone number

~An email for sending them EGLLC notices

~Date of Birth

Just to be clear, Elemental Guidance's services are provided completely through audio/video telehealth (i.e., videoconferencing) by providers residing in Hawai'i. By checking below, you acknowledge being aware of this.

Got it! Can't wait! How do we get started?!

I'm on the fence about telehealth, but willing to give it a try.

Nevermind. I wanted to see someone in-person.

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This form was created inside of Elemental Guidance, LLC.