Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Gender *

Male

Female

Prefer not to say

Type of Counseling *

Individual

Couples/Marriage

Family

Pre-Marital

Have you had counseling in the past? *

Yes

No

If you are under the age of 18, are your parents/primary caregivers:

Married

Divorced

Separated, living in different houses

Together, not married

Marital Status *

Single

Married

Divorced

Widowed

Do you prefer sessions:

Online

In person

Either

Were you referred to by an outside organization that is taking on all or part of the financial obligation? ie: church, non-profit

Yes

No