Name
*
First Name
Last Name
Email Address
*
May we contact you by email?
*
Yes
No
Phone
*
(###)
###
####
May we leave a message for you at this phone number?
*
Yes
No
What type of counseling service are you requesting?
*
Please indicate which type of counseling you are requesting.
Partner's Name (optional - for couples counseling)
Partner's Email (optional - for couples counseling)
Partner's Phone Number (optional - for couples counseling)
Fee Requested
*
Please check the box below showing the fee that you are requesting. A limited number of sliding scale fee appointments are available with associate clinicians upon request.
I need the following appointment schedule:
Check all that apply.
I want to address the following issues in counseling:
*
Check all that apply.
Is there other information you would like to provide?
Please provide a brief comment in the space below.
If you would like to select a specific counselor after reviewing our counselor profiles, please indicate the counselor you request below.
When considering your scheduling needs, please note scheduling availability and fee range for each of our therapists below.
Notice regarding email communication.
*
This form will be submitted to the Relationship Counseling Center of Austin (RCC Austin) via email message. Email is a convenient form of communication, but confidentiality of the information submitted cannot be guaranteed due to email providers storing information on their servers. It is possible that your form submission could be viewed by a third party. By submitting this form, you are acknowledging the risk, however unlikely, that may be involved in submitting this form.
