New Client Counseling Form

Please fill out the form. Once the form is submitted, we will email you with specific times that are available within one business day.

Please take the free Core Values Index Assessment, it is a required assessment for all our clients, in order to serve you best.

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

First Name *

Last Name *

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

Individual Counseling for myself

Individual Counseling for an Adolescent (ages 10-19)

Other

When Is The Best Time For Us To Call You? *

Mornings: 7:30am-9:00am, Monday-Friday

Afternoons: 3pm-6pm, Monday, Wednesday or Thursday

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

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