Name

First Name

Last Name

Subject

Message

Counselor

Please note that your preferred counselor may not be available. We will do our best to match you with a counselor who is a good fit! We will take into consideration the counselors specialty areas and schedule.

I understand and agree that any information submitted will be forwarded to the office of Rehope Counseling, PLLC by email and not via a secure messaging system. This form should not be used to transmit private health information, and Rehope Counseling, PLLC disclaims all warranties with respect to the privacy and confidentiality of any information submitted through this form. I understand that by submitting this form I am consenting to being contacted via phone or email by Rehope Counseling, PLLC.

Agree