Contact

Name *

First Name

Last Name

Phone

(###)

###

####

Check for preferred communication:

Text

Phone Call

Email

Check the boxes that best describe what issues you’d like to address in counseling?

Anxiety

Grief

Relationship Issues

Panic Attacks

OCD

Eating Disorder

Anger

PTSD

Postpartum Depression

Issues related to motherhood

Depression

Stress

Feeling Overwhelmed

I'm not sure.

Someone told me I need counseling

I just need to talk to someone.

Other

Do you prefer in-person or virtual sessions?

In-person

Virtual

A combo of virtual and in-person

Please indicate all days and times you are available to schedule a session:

Mon 9am-12pm

Mon 12pm-3pm

Tues 9am-12pm

Tues 12pm-3pm

Wed 9am-12pm

Wed 12pm-3pm

Other:

Please select *

I would like to schedule a session with Greenhouse Counseling.

I would like to schedule a Walk & Talk session.

I would like more information about Greenhouse Counseling.

I am interested in getting more information about Walk & Talk sessions.

I would like more information about the therapy group for Moms.

How did you hear about Greenhouse Counseling? *

A friend

Another counselor referred me

A doctor referred me

A Google Search

Facebook

A podcast

Other

I would like to receive free resources and updates from Greenhouse Counseling.

Yes

No

Payment Options

Please indicate your preferred payment option

Private Pay

BlueCross Blue Shield

Unsure

Name *

First Name

Last Name

Phone

(###)

###

####

Preferred Communication *

Email

Text

Phone Call

How did you hear about the Therapy Group for Moms? *

A friend

A doctor

Facebook

Greenhouse Counseling's website

I am a current client.

Other

Please indicate your interest level in the therapy group

Very interested

Somewhat interested

I'm not sure