Name * First Name Last Name Email * Phone * (###) ### #### What is your preferred method of contact? * Phone - Voicemail Email Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Age * Must be over 18 I qualify for the Affordable Counseling Program * * Our Affordable Counseling Program is for those that make under $65,000/year. Sessions are on a sliding fee scale of $25-65/session. The Luke Bell Memorial Affordable Counseling Program is for clients in need and who can't afford the current market rates for counseling. Yes No What is the amount you can afford to pay? * Amount must be over $25 $25 $35 $45 $55 $65 Other How did you hear about the Luke Bell Memorial Affordable Counseling Program? * If you have a therapist or an agency you are already working with or with whom you would like to work, please list the name and contact information here. If you are not yet established with a provider, the committee will help you to access a counselor based on availability and you will be contacted by a therapist in the next five business days. * Thank you!
