First Name

Last Name

Phone *

Email *

Postal code *

Services for *

Therapy Services for Adult

Therapy Services for Couple

Therapy Services for Family

What's the Best Way to Contact You? *

Briefly Describe The Issue You Would Like to Work On *

Provide 3 Times The Client Is Available for Counseling *

If using insurance, who is your insurance company? *

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 CCFC and CPFH therapists and/or office staff communicating with me via email or text message.