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 $35 $45 $55 $65 Other Please list the name and contact information of the therapist or agency you are already working with, or with whom you would like to work. * Please share 2-4 sentences about how the support you've received from the LBMACP has changed your life or helped you through a difficult time. * Thank you!
