Request for a Skype or Phone Session

Individual

Please fill out the following contact information:

Name

Gender

Address

Phone Number

E-Mail Address

Type of Session

Skype Address

Phone Number to Call

Requested date and time of session: (please enter three)

First Choice:

Second Choice

Third Choice

Tell us a little about yourself and why you are requesting this appointment:

Is there any abuse in your background? What type(s)?

How did you hear about us?

Have you read Journeys of the Heart — Mary’s Story?

Terms / Disclaimer:

None of the Team members who walk with you claim to be mental health professionals, counselors or therapists. All advice given comes from their journeys with their hearts and the journeys they have walked with others. We cannot guarantee the results of these services. Psychological services are not provided through these sessions. Using this service does NOT imply a client-facilitator relationship. If you or someone you know is having an emergency, call 911 immediately or go to your nearest Hospital Emergency Room.
I have read and understood the Terms / Disclaimer.