Affordable Counseling Program Consultation Form (Rejuvenated Minds Therapeutic Services)
  • PLEASE READ AND COMPLETE THE FORM BELOW: Clients enrolled in the Affordable Counseling Program will receive one year of therapy services at for free or at a discounted rate from our trained counseling residents. Sessions will be held on a virtual platform (telehealth). This is NOT an insurance based program. Currently, Maryland Residents can enroll in this program. Availability is limited.
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First Name and Last Name: *
Email Address: *
Phone Number:
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Age:
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Please provide your desired Pronouns
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State of Residence:
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Why are you seeking counseling services (Presenting Issue)
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What would progress (during therapy process) look like for you?
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Have you enrolled in therapy in the past?
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Current/ Prior Diagnosis or/ and Medication(s)
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Where did you locate our services?
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