Schedule a Counseling Appointment in Advance

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Already completed the intake form?
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CounselorK Online Uses:

Schedule an Appointment in Advance

Phone counseling is one of the best ways to get help when you need it. You don't have to leave the comforts of your own surroundings, whether at home or office. Our Phone & Webcam Counseling offers a fast and affordable alternative to scheduling an office appointment with a therapist.

The first step is to complete the intake form below. You will then be given the options of contacting us directly through Skype (a free world-wide phone service) or having us call you as soon as we are available.

To begin counseling with a scheduled appointment, please complete the form below. Once submitted you'll be prompted to pre-pay through PayPal. We look forward to working with you

CounselorK Online

APPOINTMENT FORM

Please complete the details below and we will schedule your appointment and respond as quickly as possible.

*Your Name:

*Email Address:

*Street Address:

*City:

*State (Abbreviation):

Zip:

APPOINTMENT REQUEST - DATE & TIME

Select a preferred day/date:

Preferred Time (Please list 2 choices):

(Example "10 am or 2 pm")

COMMUNICATION OPTIONS

Please contact me at the scheduled time using:

Skype ID, Phone, Cell Number or Alternate Email
Address for scheduled appointment:

Webcam?

(Please check if applicable)

(Click HERE to find out more about Webcams)

Emergency Contact Name:

Emergency Contact Phone Number:

What are your counseling needs?

Have you ever had counseling before? If so, please provide a brief description.

COMMENTS:

Form Verification - Please identify the image by selecting it from the pulldown menu:

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