Consultation Request
This is a short form to help us both determine whether or not I would be a good fit for what you are looking for. Please fill this out and I will reach out to you with 48-72 business hours. 
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Email *
First and Last Name *
Phone Number  *
Identified Problem: *
Are you looking for individual or couples therapy? *
If you're interested in couples therapy, please enter your partner's first and last name, email address, and phone number below. If this doesn't apply to you please enter "N/A" *
Any previous treatment or diagnoses?  *
Do you anticipate using insurance? If so, what company are you with?  *
What state do you live in? *
Readiness to start: *
Do you prefer in-person or virtual sessions? *
Miracle question: If counseling does exactly what you want, how will your life be different? *
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Re-Written Counseling Service, LLC.