Request Outpatient Mental Health Counseling

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

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Primary Subscriber's Date of Birth (if not patient)

MM

DD

YYYY

Are you willing to work with a masters level intern clinician supervised by a licensed therapist at a private pay rate of $25 an hour for up to 6 sessions.

Yes

No

What is your appointment location preference? *

Waunakee and Tomah in-person waiting lists are 6-12 months or longer. Consider also selecting virtual to lessen your wait time.

Check all that apply.

Reedsburg Office

Tomah Office

Waunakee Office

Virtual

How did you hear about us?

Friend or Co-worker

Google

Other Search Engine (Bing, Yahoo, etc.)

Facebook

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Trailways Counseling Staff Member

Other Counseling Service