Counseling Application

If you are ready to talk about establishing a counseling relationship, we are eager to help.

In order to begin understanding your situation and to determine the best way to help, we ask that you provide background information and agree to a professional services agreement. (If you would like to review our Privacy Policy, see CPC Notice of Privacy Policy.)

Full Name

Age

Country of Origin

Ethnicity (optional)

Languages spoken (in order of preference)

Religion

Current Address

Time Zone:
GMT (e.g. "+5" or "-8")

Email

Okay to send a message?

Phone

()
Okay to leave message?

Emergency Contact
(name and quickest way to contact -- counselor will discuss this with you during your first session)

Current Occupation

Highest Educational Level/Degree

Spouse's Name

Spouse's Age

Spouse's Country of Origin

List others in your household, one line per person:
Name, Age, Relationship, Occupation/School Age

When were you last seen by a physician?

Purpose of last visit?

Major illnesses (describe nature and date)

List any medications you are now taking

Please describe any previous counseling/psychiatric services (When, what for, how long, and outcome)

Briefly describe your reason for wanting counseling at this time

Please check any of the following issues that you want help with:

Other Issue(s):

I confirm that I have high speed Internet access and have a webcam.
I have read, understand, and agree to the conditions outlined in the Professional Services Agreement.
Electronic Signature
By typing my name in the following box, I provide my electronic signature:

Enter this code to prove a person is filling out the form:
captcha

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