First Name *

Last Name *

Phone *

Email *

Location *

Whom Are You Seeking Counseling For *

Briefly describe the issue you would like to work on. *

What's the Best Way to Contact You?

**STOP --> Have you reviewed our Private Pay policy?

Have You Read Our Private Pay Policy? *

Yes

Would you like to receive our best mental health advice sent to your email?

Yes

How did you hear about us? *

Email Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Fearlessly Inspired Therapeutic Solutions LLC therapists and/or office staff communicating with me via email or text message

I agree to the privacy policy provided by Fearlessly Inspired Therapeutic Solutions LLC. By providing my phone number, I agree to receive text messages from the business.

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