No information leaves this office without signed release. All information is privileged and confidential to the extent permitted by law.
Please list significant relationships. (Ex: Married, Divorced, Widowed, Open, Dating, Separated, etc.)
What type of counseling are you seeking? Please choose one and note Forms Required.
List all current medications you are taking, including those you seldom use or take only as needed:
Please a value on the scale below to indicate how distressing your problem(s) are to you.
1 = Minimally Distressing
5 = Moderately Distressing
10= Extremely Distressing
Clicking SUBMIT will take you to the next form that is required.