Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth

MM

DD

YYYY

What type of counseling are you looking for? *

Individual

Marriage

Teen/Adolescent (ages 14-18)

Privacy and Security *

I understand that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information I include in an email can be intercepted and read by other parties besides the person to whom it is addressed. I also understand that Amy Standifer or Erika Zuno will coordinate our initial phone consult after I've scheduled it through Simple Practice. I give her permission to leave me a message at the phone number and email address provided.

I Consent to receive an email correspondence.

I Consent to receive text messages.

I Consent to receive a phone call, OKAY to leave a voicemail.