name *

First Name

Last Name

intentions *

What is the main challenge / concern that prompted you to seek counseling? What're you looking to heal? (Please select all options that apply.)

Codependncy

Sexual Trauma

Anxiety

Depression

Other

financial resources *

(Please select all options that apply.)

You’re ready to fully invest in your Self & you have access to financial resources to do so.

You acknowledge the value of counseling, but you're limited by your current financial circumstances.

You're interested in counseling, but you have dissonance about your financial resources.

You’re lacking in resources to invest in your Self fully, but you want to take a step towards your Self growth.

You're interested in a payment plan option.