Contact

To schedule a counseling session, please complete the contact information form below and let me know more about what you are struggling with. Counseling services are provided for a donation of your choice, if you are able, but is not required. All counseling sessions are conducted via Zoom. I will respond to your inquiry promptly.

Contact Information Form

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Age *

Marital Status *

When would you like to get started? *

Which day of the week works best for you? *

What time of the day is best? *

What are you currently struggling with? *

What would you like to see change or be different? *

List all medications you are currently taking: *

List all professionally diagnosed current conditions: *

List all previous counseling, psychiatric hospitalizations, and/or suicide attempts with approximate dates: *

Are you a Christian? *

Yes No

Are you interested in learning more about my weekly Women's Bible Study? *

Yes No

Additional Comments: *

Please Read: Counseling sessions are conducted via Zoom. Please be sure you have Zoom downloaded to your computer or phone. A Zoom meeting link will be provided to you in advance of our session. Thank you!

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If this is an emergency, please call:

SUICIDE HOTLINE: (800) 273-8255
ABUSE HOTLINE: (800) 799-7233
ADDICTION HOTLINE: (800) 662-4357
SEXUAL ASSAULT: (800) 656-4673
MENTAL HEALTH: (800) 950-6264

Schedule Session

Contact Information Form