Appointment Request Form
Please complete the following form to request your appointment.
First Name
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Last Name
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Phone
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Email
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Would your like first availability or work with a specific clinician?
First Availability
Geneva Gonzalez
Fran Singson
Ariel Birkholz
Grace Talbott
Sarah Cordova
Holly Steverson
Ben Hickman (Virtual only)
Megan Ortiz (Waitlist)
Josh Freeman (Waitlist)
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Whom Are You Seeking Counseling For
Self
Couples
Child
Family
Parent/Guardian
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How did you find us?
How did you find us?
Google Search
My Insurance Company
PsychologyToday
My Pastor or Church
Linked In
Facebook
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My Chiropractor
My Physical Therapist
My Pain Management Doctor
My Family Doctor or Nurse Practitioner
A Current Or Past Client of Counsel RVA
Sondermind
I am a past client
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