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Please select what best describes the reason you’d like to meet with a counselor (select all that apply)

Anxiety and stressProblems with mood (e.g. depression)FearSubstance use or abuse (alcohol or other drugs)Addictions or compulsive issuesRelationship or social problems (interacting with others)Marriage, couples or family counselingChild or adolescent counseling

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Preferred Date

Regular Counseling Hours: Monday-Thursday: 9:00am-8:00pm Fridays: 9:00am-5:00pm

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Therapist Please note: Selecting a specific counselor may limit appointment availability. If you leave this section blank, we will assign you a counselor that is appropriate for your issues, and with availability nearest to your requested appointment time.

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I grant Capital Counseling permission to contact me to discuss the subject for which I am seeking assistance. I understand that this form is not monitored at all times and is not intended for emergencies or immediate response. I understand that it may take until the following business day for a response.I acknowledge that I have read and understand the attached HIPAA statement.

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