Legal Name *

First Name

Last Name

Phone Number: *

(###)

###

####

Upon agreeing to giving us your phone number the following is noted:

I agree to receive text communication from you. Msg & data rates may apply. Messaging frequency varies.

I agree.

I am 18 years or older or an assigned representative of the person coming in for counseling that is 18 years or older. *

I agree.

Do you need to inquire about reduced rate services?

Yes, I need more information.

No, not at this time.

Are you interested in a 15 minute consultation with CJ before scheduling? *

Yes - please contact me for setting this up.

No - I would just like to schedule an appointment.

Unsure - can you please provide more infromation?

Cancellation Fee/Credit Card Policy *

I understand by sending this inquiry, if I am to establish services with CJ that I will be subject to putting down a valid credit card number to hold my appointment. Guardian Pack Counseling has a 24 hour cancellation policy and the card will be charged the according fee for the service if notice. In the event of an emergency and needing to cancel, please let our staff know.

I agree.