Application for 48 Week Small Group Intensive Counseling Program
Email address *
Name *
Your answer
Email *
Your answer
Address *
Your answer
Phone number *
Your answer
Time Zone *
Write out a quick synopsis of your life story. Focus only on the events that stand out when you look back over your life. (These are emotionally charged memories, which is what we are looking for.) *
Your answer
When you think back over the experiences in your life, what is the one most important lesson you have learned about life, the world, and the people in it. *
Your answer
If I had a magic wand and I could do anything for you, what would you like me to do for you personally? *
Your answer
How many cumulative years of counseling have you had in your life? *
What diagnoses, if any, were given to you. If none, write n/a. *
Your answer
Have you ever been diagnosed as Treatment Resistant? (Treatment Resistant clients are welcome.) *
Are you currently on any medication for depression, anxiety, bipolar, PTSD, stress, or any other diagnosis? *
Which choices of Counseling Groups are you interested in? (You can select more than one.) *
Required
During which 2 hour slots would you be available for sessions? Please check all possibilities. *
Required
Would you be paying in installments or all at one time? *
What could pull you out of the program? (There are no refunds unless the Counselor ends the program, at which time all incomplete future sessions would be refunded in full.) *
Your answer
What questions do you have about the program? *
Your answer
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