Intrepid Counseling Secure Contact

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

What can we help you with?

Brianna White is licensed in Washington and Georgia in the U.S. and cannot work with clients located elsewhere in the U.S. or Canada. Locations outside the U.S. and Canada Brianna can consider on a case by case basis. *

Yes, I am in Georgia or Washington state U.S.A.

I am located outside the U.S. and Canada.

I need help finding a referral in the U.S. or Canada because I'm not in Georgia or Washington.

Other:

Required

First Name

Last Name

Email address

Are you willing to receive a response to this inquiry by email? Consider that conventional email is inherently insecure and therefore poses a risk to the privacy and security of your Protected Health Information. If you consent, Intrepid Counseling may communicate with you with via unsecured email with regards to scheduling, billing and payment for healthcare services. You are not required to give consent this consent in order to receive treatment. *

Yes. I accept these risks and consent to unsecured email.

No, please use the phone to contact me.

Required

Phone Number *

Is it ok to leave a voice message at this number? *

Yes

Your contact is related to

Yourself or someone in your family

Someone outside your family

Other:

Clear selection

Date of Birth (of the person who counseling will be for) *

YYYY

What is your address, including country?

How can I help you?

How did you hear about Intrepid Counseling?

Google Search

Referral by staff care

Referral by friend

TCKcounseling.com

International Therapist Directory

Families in Global Transition Directory

Other:

Good Faith Estimate: Beginning in January 2022 a new law called the No Surprises Act requires therapists to give a good faith estimate of the cost of their services to anyone who inquires. Brianna White's fees are as follows: $200 for initial assessment, $100/session, usually weekly. More fee information is available at https://intrepidcounseling.org/service-fees/

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Intrepid Counseling. Report Abuse

Forms