Contact Us
If you have any questions regarding our services, please contact us by calling or e-mailing us and we'll get back to you as soon as possible.
We will never divulge your contact information to anyone - ever!
We will not confirm or deny that you are a client! Your confidentiality is assured.
We look forward to hearing from you.
Your Email is automatically encrypted, very secure and completely confidential.
New!
Our New Online Client Intake Form.
It is completely secure, HIPAA compliant with 128 bit SSL encryption.
We offer a $10.00 Olive Garden Gift Card at your 1s
t
session with a completed, accepted online new client form.
(Two to a Family Max.)
Click here for form
First Name
*
Last Name
E-mail Address:
*
Telephone
How should we contact you?
*
Cell Phone
Home Phone
Work Phone
Text Message
Email
May we leave a message?
*
Yes
No
When should we contact you?
Morning
Afternoon
Evenings
Weekends
Anytime
As soon as possible!
What type of counseling are you seeking?
Individual
Couple
Child (Min. Age 8)
Family
Group
Other - See comments
Will you be using insurance?
Yes
No
Insurance Provider
Please select your provider
Aetna
Beech Street
Blue Cross / Blue Shield
Cigna
Crime Victims Reparations
Educators Mutual
Federal Blue Cross
GEHA
Humana
Mailhandlers
PEHP (Summit Care Only)
Regence ValueCare
Tricare
UBH
Uni Behavioral Health
United Behavioral Health
United Health Care
Value Options
Vocational Rehabilitation
Other - Please enter in Comments
Preferred Counselor
Sharon St. John, LPC
Karolee Alexander, LCSW
Dont Care
Age of client
Comments
*
Required
