Name * First Name Last Name Email * Phone * (###) ### #### What is your preferred method of contact? * Phone - Voicemail Email Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Age * Must be over 18 I qualify for the Affordable Counseling Program * * Our Affordable Counseling Program is for those that make under $65,000/year. Sessions are on a sliding fee scale of $25-65/session. The Luke Bell Memorial Affordable Counseling Program is for clients in need and who can't afford the current market rates for counseling. Yes No What is the amount you can afford to pay? * Amount must be over $25 $25 $35 $45 $55 $65 Other How did you hear about the Luke Bell Memorial Affordable Counseling Program? * If you have a therapist or an agency you are already working with or with whom you would like to work, please list the name and contact information here. If you would like our help finding a therapist who meets your needs, tell us about your reasons for seeking counseling in not more than 3 sentences. We will work to find the best fit for you, and you will be contacted by a therapist in the next five business days. * Thank you!
