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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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