Self-Pay Contact Form Living Water Counseling Ministry

Self-Pay Contact Form

Note: I am not providing Marriage/Couples Counseling at this time. I only provide Individual Counseling to Adults 18 yrs and up.

***If you have not received confirmation that this form was received by email in 3-5 business days please resubmit the form as it likely was not received***

Client Name*

Client Gender*

Email Address*

Do you have any form of health insurance (Medicare, Medicaid, Health Insurance, etc)?*

Do you have current or pending legal issues?*

Yes

Are there any certain days or times you would need services due to other obligations?* (Current appointment hours are Monday, Wednesday, Thursday 10:00 am-5:30 pm. I am closed Tuesday, Friday, Saturday, and Sunday)

How often were you planning to attending counseling services* (Once per week, Twice a Month, Once a month, Unsure, etc)

What issues/problems were you wanting to address in counseling services?* (Anxiety, Depression, Grief/Loss, etc)

What state do you currently reside in? * (Counselor is only licensed to practice Telehealth in Virginia and North Carolina)

Please be aware that all counseling sessions are by Telehealth Only. You will need access to the Internet, your own phone for counselor to get in touch with you in case of technical difficulties during the session and your own email address where you can receive appointment reminders and document requests. Please be aware that not all issues/problems are appropriate for Telehealth mental health counseling services. If at any time counselor feels you would benefit more from In-Person Counseling Sessions then you will be given referrals to other providers in your area.

Message (Optional)

Your form has been submitted! Please allow 3-5 business days for a response. Thanks!

Living Water Counseling Ministry. Telehealth Services. Virginia & North Carolina. Christian Counseling. Substance Abuse Treatment. Mental Health Psychotherapy. Individual Services. Anxiety. Depression. Panic Attacks. Seasonal Affective. Grief/Loss. Spirituality. Women's Issue., Addiction. Alcohol Use. Bipolar Disorder. Career Counseling. Coping Skills. Drug Abuse. Dual Diagnosis. Emotional Disturbance. Infertility. Mood Disorders. Pregnancy, Prenatal, Postpartum, Self-esteem. Stress. Life Coach.