First Name *

Last Name *

Phone *

Email *

What's the Best Way to Contact You?

Whom Are You Seeking Counseling For *

How Would You Like To Receive Services *

In-Person Only

Telehealth Only

Open to Both

Briefly Describe The Issue You Would Like to Work On *

Provide 3 Times The Client Is Available for Counseling *

Would your like first availability or to work with a specific clinician? *

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 clinicians and/or office staff at ReAlign Wellness Group communicating with me via email or text message.