Name *

First Name

Last Name

Phone *

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I am seeking these services: *

Individual Counseling

Couples/Relationship Counseling

Adult Family Counseling

Veteran Counseling

For Relationship Therapy, enter PARTNER'S NAME and INFO here. Additional members can be added at the bottom of form.

First Name

Last Name

Phone

(###)

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I prefer: *

In-Person - New Braunfels, TX

Virtual Only

Combination of In-Person & Virtual

Mostly, I'm looking for help with: *

Anger Management

Anxiety/Stress

Career Exploration/Transitions

Communication Issues

Conflict Resolution

Depression

Divorce/Separation/Break Up

Grief/Loss

Infidelity

Life Transitions

Low Self Esteem

Low Sex/No Sex

Military Life/Challenges

Opening Up Relationship

Parenting

Personal Growth

Relationship Issues

Sex "Addiction"

Sexuality/Exploration

Trauma/PTSD

I'm available during these days and times:

Mondays *

Morning

Afternoon

Not Available

Tuesdays *

Morning

Afternoon

Not Available

Wednesdays *

Morning

Afternoon

Not Available

Thursdays *

Morning

Afternoon

Not Available

Fridays *

Morning

Afternoon

Not Available

How did you hear about us?

Personal Referral

Referred by Counselor

Referred by Doctor

Internet Search

Psychology Today

Facebook

Instagram

TikTok

Linked In

Podcast

Blog

You Tube

Other

Please read and check BOTH boxes: *

I verify that I am the person seeking services for myself.

I understand that Visionaries of Living in Color DOES NOT accept insurance payments and I can seek reimbursement directly from my insurance company.

Name

First Name

Last Name