Limitless Counseling and Consultation, LLC: Waitlist and Client Interest Form
Thank you for considering Limitless Counseling and Consultation, LLC, where we explore without limits! We are honored to assist you in your counseling needs and will contact you as appointments or requests become available. Please complete all information below.  By completing this form, you understand and consent to the following: 

By completing this form, I understand and agree: 
-This is a non-binding and tentative agreement to receive contact from Limitless providers
-This is not a guarantee of clinician client relationship, and I am not an established client without an appointment and adequate consents.
-I am at least 18 years of age
-This form is not an emergency resource and if I am in danger, I should: 
         -call 911 or my local emergency services OR 988 for mental health crisis, or use the following emergency resources: Text "Talk" to 741741; call the Georgia Crisis Line 1-800-715-4225

By completing this form, I consent to:
- Limitless providers using my information to contact me for the purpose of scheduling an appointment


 To be removed from our waitlist, please email us at: limitlessndrconsulting@gmail.com. We will connect with you soon! If you are requesting other mental health services outside individual, please email us, or call us at 762-233-4945. 
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Name of Client (put all who apply if applicable) *
Parent/Guardian for Minors (please put "NA" if not applicable) *
Email *
Full Address (please include city, state, and zip) *
Age of Minor Client (17 or younger; Mark "NA" if not applicable) *
Phone number *
What services are you interested in? *
Who are you interested in working with? *
Required
How will you pay for your sessions? *
What is the best way to contact you and at what time? *
Morning (8am-12pm)
Afternoon (12pm-5pm)
Evening (after 5pm)
Phone
Email
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