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Service Inquiry
Anyone interested in working with COEXISTUS must fill out this form. A representative will respond shortly via email to schedule the call or provide a referral to another service provider.
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Name
*
Your answer
Best Email Address
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Your answer
Best Phone Number
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Your answer
City, State, and Country where you are currently living:
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Your answer
Please provide a brief description of why you are seeking services at this time and what have you tried so far to improve the situation.
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Your answer
Which service(s) are you most interested in at this time?
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Counseling
Coaching
Education
Facilitation
Mediation
Parent Coordination
I don't know at this time.
Required
Who are the other people in your interpersonal/family system whom you may like to invite to participate in a service with you?
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Your answer
Do you have any safety concerns for yourself, your children, and/or others in your interpersonal/family system? If so, please provide us with a summary of your perspective/experience(s).
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Your answer
Availability for scheduling a free 15 minute individual phone call
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I'm available for a phone call any time
I'm available outside of traditional business hours of 9-5 PM.
Other:
How did you hear about COEXISTUS?
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Web Search for Collaborative Divorce
Web Search for Counselors
Web Search for Educational Classes like Anger Management, Parent Education, Abuse Prevention
Web Search for Mediators
Friend / Family Member
Counselor
Judge / Court
Attorney
Probation / Parole
Psychology Today
Association of Professional Family Mediators
Oregon Mediation Association
Other:
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