Patient Name *

First Name

Last Name

Name of Person Completing This Request *

First Name

Last Name

Phone *

(###)

###

####

What services are you interested in? *

Please check all that apply.

Individual Teletherapy

Couples/Marital Teletherapy

Family Therapy

What are the issues? *

(Please check all that apply.)

Anxiety

Behavioral Problems

Communication/Social Challenges

Depression

Infidelity

Obsessive Compulsive Behaviors

Military life stress

Trauma

Other

If you are choosing the out-of-pocket route, are you aware of and do you accept the $150 per hour self-pay rate? *

Yes

No

N/A

Are you aware that we only provide teletherapy services and do not offer in person counseling services? *

Yes

No

Is the identified patient currently residing in South Carolina or North Carolina? *

The identified patient must be currently residing in South Carolina or North Carolina to receive virtual services from Reunion Health.

South Carolina

North Carolina

Do you have a preference in which counselor you'd like to work with? *

Nicole

Barbara

Kellie

No Preference