**Notice**

 Due to current health concerns, I will no longer be accepting any new clients until further notice. 

Thank you.

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Personal Information

First Name        Middle Initial        Last Name  

Street Address        Apt. #  

City        State        Zip  

Phone        Cell Phone        E-Mail  

Reason for contacting VideoBasedCounseling.com

Schedule an appointment     Cancel a scheduled appointment (24 Hrs in advance)  

Technical support     Question or Comment      Volunteer      Employment

I will respond to all requests via e-mail unless you ask to be contacted otherwise.

Please use this area for questions or comments