Name

First Name

Last Name

Phone

(###)

###

####

I understand Creating Changes Counseling is an Out-of-Network organization and after my complimentary 15 minute consultation, 50 minute sessions are $185. *

Yes

No

I would like information on how to use my Out-Of-Network Benefits

I understand that communications over the internet are not secure. Although it is unlikely, there is a possibility that information I include in an email or submit in this form can be intercepted and read by other parties besides the person to whom it is addressed. I also understand that Creating Changes Counseling will reach out to coordinate our initial consult. I give Creating Changes Counseling permission to leave me a message at the phone number and email address provided.

I Agree