First Name
*
Last Name
*
Phone
*
Email
*
Address
*
Postal code
*
Whom Are You Seeking Counseling For
*
Self
Couples
Child
Family
Teen
Parent/Guardian
No elements found. Consider changing the search query.
List is empty.
How would you like to receive services?
*
In-Person Only
Telehealth Only
Open to Both
Briefly describe the issue you would like to work on.
*
What's the Best Way to Contact You?
Phone
Email
Text Message
No elements found. Consider changing the search query.
List is empty.
How did you hear about us?
*
Email Risk Acknowledgement and Use Consent
*
I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Legacy Counseling therapists and/or office staff communicating with me via email or text message
(WAIT! Click the button only once & wait for this page 2-3 seconds to load)
Submit