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First Name

Last Name

Phone

Birthday

How did you hear about us?

Tell us about what you're dealing with...

What services are you interested in? * Required

Individual Therapy

EMDR

Low Cost Counseling with a Student or Intern

Couples Counseling

Family Therapy

Play / Child Therapy

Teen Therapy

Coaching

ADHD Testing

Hold Me Tight Workshop (Couples w/ Rebecca Maxwell)

Couples Therapy Intensive

Hold Me Tight® Couples Intensive

EMDR Therapy Intensive

Full Therapeutic Disclosure Intensive (Infidelity with a CSAT)

Betrayal Trauma Intensive

Couples Stabilization Intensive (Infidelity)

Sex & Porn Addiction Recovery Intensive

Betrayal Trauma Support Group

ADHD Support Group

Primary Concern

If you checked "Other" above, what other service are you interested in?

Is there a specific therapist you are interested in seeing? Feel free to tell us anything to help us match you with a therapist.

In -Person or Virtual

If in person isn't available, are you comfortable being virtual?

What state do you live in?

How would you like us to contact you? * Required

Text

Phone Call

No Preference

I acknowledge that Jacksonville Counseling Services does not accept insurance, operates as an out-of-network provider, and can provide a superbill for potential reimbursement; I understand it is my responsibility to contact my insurance company regarding coverage.

Thanks for contacting us! We will be in touch within 48 hours on business days!

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