New Client Counseling Form

Please complete the form, then click "Continue" to schedule a brief call with our intake specialist.

Core Values Counseling will not share your info. We respect your privacy and take protecting it seriously.

First Name *

Last Name *

State of Residence *

Email *

Best Phone Number *

Please do not use a shared phone number (i.e. company/office phone).

What can we help you with? *

Counseling: Individuals, Couples and/or Families

EMDR (Trauma Recovery)

Neurofeedback (Treats Trauma, ADHD, Anxiety, Depression and other issues)

Affair Recovery

Stress and Anxiety

PTSD Treatment

I am seeking counseling for: *

Couples Counseling for myself and my partner

Family Therapy

Individual Counseling for myself

Individual Counseling for an Adolescent (ages 10-19)

Individual Counseling for a Child (ages 5-10)

Other

What can we help you with the most? Give a brief description. *

Where would you like to receive counseling services? *

In-Person (Hillsboro, OR)

Virtual (online-only)

Both In-Person and Virtual

How did you hear about Core Values Counseling?

Google/Internet Search

I am a Current Client

Insurance Provider Directory

Referral from Friend/Family Member

Referral from a Therapist

Referral from a Church/Pastor

Psychology Today/Good Therapy

Other

By providing your number and checking this box, you agree to receive periodic text messages from Core Values Counseling LLC. These text messages will provide valuable information about your purchases and updates about our programs. Standard text rates apply. Reply STOP at any time to unsubscribe. I agree to the Terms of Service provided by Core Values Counseling LLC.