APPLICATION FOR SERVICES
Name
Phone Number
Email Address
How would you like me to contact you?
How will you be paying?
Blue Cross Blue Shield (+ possible copay)
Health Choice (+ possible copay)
Private/Cash Pay ($75-175 sliding scale)
Which of the following times can you make work?
Mondays
11:00 am
1:00 pm
2:30 pm
4:00 pm
Tuesdays
11:00 am
1:00 pm
2:30 pm
4:00 pm
Wednesdays
11:00 am
12:30 pm
2:30 pm
4:00 pm
5:30 pm
Thursdays
11:30 am
1:30 pm
3:00 pm
4:30 pm
6:15 pm
Fridays
11:00 am
1:00 pm
2:30 pm
4:00 pm
Narcissistic Abuse Support/Treatment Groups
Wednesdays 6:15-8:15pm (biweekly)
Thursdays 12:30-2:30pm (biweekly)
What is your reason for seeking services? What symptoms are you experiencing?
Why are you interested in counseling services from Jonathan specifically? Any particular reason(s)?
How committed are you to doing what it takes to get better? Be specific.