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If you are experiencing an emergency, crisis or need immediate assistance, please dial 911 or go to your nearest emergency room. 

This form is for non-emergency contact requests only.

Please enter your contact information below.  

I will reach out to you to schedule a free phone consultation.

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Self and Other Counseling, PLLC, harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

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