The Wise Family Wellness

Hello! Please complete as much of this form as possible

so we can connect you with a therapist who is a perfect fit.

Thank you!

Seeking Services For: *

Full Name (if other than client) *

Email *

Phone *

City *

Relationship to the Client *

How can we help you? *

Location Preference *

In person (Alexandria office)

In person (Falls Church office)

Telehealth

Provide 3 Times The Client is Available for Counseling *

What's the best way to contact you? *

How did you hear about us? *

Would you like to be added to Wise Family Wellness's email list to stay up to date on our programs and services? *

STOP! Have you reviewed our Fees & Insurance page? Please note all first/intake sessions are scheduled for 60 minutes, $300. We require this fee to be paid at time of booking. Regular sessions are 45-50 minute sessions and are priced based on the clinicians rates shown on our website. https://www.thewisefamily.com/getting-started/fees-insurance/

I consent to Wise Family Wellness therapists and/or administrative staff communicating with me via email and/or phone.