Professional Counseling First Name* Last Name* Phone Number* Email* Is this for your child or for yourself? If this is for your child, please enter their name and age. Who would you like to work with? Steve Howard Jessica Jamie What will be your form of payment? Insurance Self Pay If insurance, what insurance do you have? else N/A What is your availability? In one to two sentences, please describe the presenting issue you’d like to be seen for (Ex. Depression, anxiety, stress, etc.)How did you hear about Mental Fitness? TweetShareSharePin0 Shares
