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Apply for Services

Apply for Services 2018-05-24T23:50:40+00:00

Don’t go it alone. We will help you fight this battle! Fill out this form today and get started!

Meet your therapist…

This is a confidential form. All services will comply with HIPAA confidentiality standards.

Are you suicidal?
YesNo

Which paid service are you requesting?
CounselingPsychotherapyDream TherapyDreamWorkLife CoachHuman Design

Would you prefer online counseling, face-to-face counseling (in person), or both?
OnlineIn-PersonBothI don't know