Questionnaire

Complete the questionnaire to help an E-Counselors Coach better provide support for you.  Once you have submitted the completed questionnaire, you will receive a response from an E-Counselors qualified Therapist within 24 hours via email.  From there, we will decide together what is the best means of working with you.

                

Language that you speak:

A valid email address is required in order to receive a response.

How would you prefer to receive counseling?

Thank you.  You can expect a response within 24 hours. 
Go to the
Fees Page to see what the next steps are.

By selecting the “I accept these terms” box below, you agree that service by E-Counselors is provided ‘as is’, without warranty of any kind, either express or implied, including without limitation any warranty for information, services, counseling, uninterrupted access, or products or services provided through or in connection with service.  You recognize that there are no guarantees as to the success of your relationship with a counselor or coach from this website, and you recognize that during the process of therapy, psychological pain and distress can arise as difficult issues are addressed and worked through.  You are at least 18 yrs of age or older.  If you are suicidal, call Emergency immediately or go directly to your nearest Hospital Emergency Room.  You also acknowledge  that, although E-Counselors has taken a number of steps to ensure the confidentiality of your communications with the counselor, this service cannot guarantee the security of your communications through this website.  You agree to release, discharge, and indemnify E-Counselors from all actions, suits, claims arising from receiving counseling on this site.

This will submit your questionnaire.

Age:

Why are you considering counseling?

Have you previously received counseling?  Please explain:

Please enter any questions or comments you may have:

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Phone (if you selected counseling by phone):