Name *

First Name

Last Name

Phone

(###)

###

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I’m interested in help with ... *

In Additional Message: If you are seeking help for a child, please provide his/her age. Provide a referring professional's name if applicable. Let me know how you prefer to be reached. If by phone, please confirm it is okay to leave a message if I am unable to reach you. Please choose as many as apply:

Life Transitions

Separation and Divorce

Relationship Problems

Premarital Counseling

Recent or Past Trauma

Grief and Loss

Suicidal Thinking

Depression

Bipolar Disorder

Stress and Anxiety

Obsessive Compulsive Disorder

Social Phobia

Other Phobia

Medical Crisis

Living with Other's Physical/Mental Illness or Addiction

Support with Addiction Treatment

Behavior Problems

Career Change

Healthy Weight Management

Self-Harm

Workplace Well-Being Programs

Agreement to receive text messages *

Message frequency varies and may include appointment scheduling or reminders. Message and data rates may apply. Opt out at any time by replying 'unsubscribe'.

Yes, I agree to receive text messages concerning scheduling from Gibbs Counseling at the phone number listed above.

No, I do not want to receive text messages from Gibbs Counseling.