Contact information

Please fill out the form below, and someone will be in touch shortly.  For your confidentiality, please do not include any additional personal information on this form. By completing the form below, you give Buzick Counseling Services, PLLC (dba: Beyond Therapy ND) permission to contact you by email, phone, or text. 

If you are in need of immediate help, please go to your nearest emergency room.  

National Suicide Hotline:  988

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We are in network with a number of insurance companies which may help you offset the cost of your therapy services. To make sure we are an in-network provider, which insurance company do you use?  *
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