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Application for Reduced Fee

Please complete all fields.

NOTE: If you prefer not to submit this information via email, please leave a confidential voice message for Dr. Smith @ 1.800.705.6223, ext. 101, and provide the information by phone.

Name:

Email:

Phone:

Street:

City:

State:

ZIP Code:

Employer:

Job Title:

Spouse:

Employer 2:

Job Title 2:

Number of Minor Children Living at Home:

Total Monthly Income (or budget):

Type of Counseling:

Individual Counseling for Myself

Individual Counseling for My Spouse

Individual Counseling for My Child

Family Counseling

Marriage Counseling

Premarital Counseling

Counseling for Dating Couple

Purpose of Counseling:

Counselor Preference:

Referred by:

We respect your email privacy

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