First Name

Last Name

Phone

(###)

###

####

I understand sessions are $200 per 50 minutes. Creating Changes Counseling is an out of network provider and does not bill with in network insurance. *

Yes

No

I confirm that I am not in crisis, experiencing suicidal thoughts, or in immediate danger. I understand that this form is not monitored 24/7 and is not for emergency situations. If you are in crisis or experiencing suicidal thoughts, please call 911, go to the nearest emergency room, or contact the Suicide & Crisis Lifeline at 988. *

I Agree

I understand that communications over the internet are not secure. Although it is unlikely, there is a possibility that information I include in an email or submit in this form can be intercepted and read by other parties besides the person to whom it is addressed. I also understand that Creating Changes Counseling will reach out to coordinate our initial consult. I give Creating Changes Counseling permission to leave me a message at the phone number and email address provided.

I Agree