Name

Phone

Email Address

Location LocationSanta CruzWatsonvilleMontereyMonterey or WatsonvilleWatsonville or Santa CruzAny

Combined Household Income Combined Household Income$0 ~ 2,000 per month$2,000 ~ 3,000 per month$3,000 ~ 4,000 per month$4,000 ~ 5,000 per month$5,000 ~ 6,000 per month$6,000 ~ 7,000 per month$7,000 ~ 8,000 per month$8,000 or aboveother

# of People in Your Household # of People in Your Household123456 or more

Health Insurance Coveage Health Insurance CoveageNo InsuranceMedi-CalHigh Deductable InsuranceOther

Age of person seeking counseling

Type of Service Type of ServiceFamily TherapyCouplesInd. AdultInd. TeenInd. ChildGroup TherapyOther Services

Issue you want help with Issue you want help withAlcohol & Drug UseAngerAnxiety, Panic, PhobiasAttention DeficitBehavior ProblemsCareer/Employment IssueChronic IllnessCo-dependency/ACACommunication SkillsDepressionDivorce/SeparationEating DisorderGrief/LossRelationship ProblemOther (describe below)Co-parent Counseling/MediationDomestic ViolenceInfidelityLGBTQ Identity/RelationshipsMen's IssuesWomen's IssuesMindfulnessStress ReductionParenting/Step ParentingFamily MediationAlternative RelationshipsSex CounselingSpiritual CounselingTrauma Recovery/PTSDPlay TherapySandtray TherapyArt TherapyOther

Weekday Availability (Check all possibilities) Weekday Availability (Check all possibilities) Monday mornings Tuesday mornings Wednesday mornings Thursday mornings Friday mornings Monday afternoons Tuesday afternoons Wednesday afternoons Thursday afternoons Friday afternoons No Weekdays

Weekend & Evening Availability (Check all that apply) Weekend & Evening Availability (Check all that apply) Saturdays Sundays Monday evenings Tuesday evenings Wednesday evenings Thursday evenings Friday evenings No Weekends or Evenings

Message (Please include details about particular needs you have)