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Our Choice healing and support services
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Intake form
Help us serve you better
Name
*
Email address
*
What is your age?
Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 and over
What type of support are you interested in?
Please select at least one option.
Individual support
Trauma support
Grief support
Have you previously received counseling?
Select
Yes
No
What are your primary concerns?
Please select at least one option.
Anxiety
Depression
Relationship Issues
Trauma
Self-Esteem
Stress Management
Life Transitions
How did you hear about us?
Select
Online Search
Friend/Family Referral
Social Media
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What is your preferred method of communication?
Please select at least one option.
Phone
Email
Video Call
In-Person
Which service or services are you interested in?
Please select at least one option.
Individual sessions
Trauma-informed sessions
Heartbreak recovery program
Initial consultation for $150
Follow-up consultation for $100
Additional questions or comments
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