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STILL WATERS COUNSELING SERVICES, PLLC

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Counseling Request Form

Fill out the form below and be on the look out for an email from a counselor.

First Name

Last Name

Email

Phone

Insurance or Private pay? If insurance, please specify your provider.

In person or Virtual?

Type of therapy. Select all tha apply *

Individual

Couple's

Play therapy/therapy for my child

EMDR

Accelerated Resolution Therapy (ART)

Foster care support

Group therapy - adult

Group therapy - child

If seeking couple's/child therapy please specify first/last name of partner/child and email and phone of partner

Best days/times for scheduling

Reason for seeking counseling

Thanks for submitting! Be on the lookout for an email in response to your form.

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