Request An Online Counseling Session Please enable JavaScript in your browser to complete this form.Session Type *Online Phone Session: 60 Minutes – $90Online Phone Session: 90 Minutes – $135Online Video Session: 60 Minutes – $100Online Video Session: 90 Minutes – $150 Name *FirstLastEmail *Phone Number *Skype UsernameCountryDate of BirthGenderMaleFemaleSocial StatusSingleMarriedSeparatedWidowedRemarriedCommitted RelationshipHave you received Counseling, Psychological, or Psychiatric Counseling before?YesNoSymptoms Checklist – Please check symptoms that apply to youSadnessCrying EpisodesHelplessnessHopelessnessWeight LossWeight GainOvereatingNausea/Vomiting Sleep Problems/Memory ProblemsLow EnergyDifficulty FocussingDifficulty Making DecisionsIrritabilityLack of General ProductivityAgitationRestlessnessPanic AttacksFear of Illness or DeathFear of Loss of ControlExcessive WorryAvoidance of Public PlacesPalpitationsChest PainShortness of BreathTrembling & ShakingNightmaresFlashbacksEasily StartledBad Intrusive ThoughtsFeeling Detached from OthersWhat would you like help with? – Describe your problem belowWhat results would you like to achieve?Payment Method *PayPalWestern UnionBank TransferEmailRequest
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