Email Scheduling Form

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Name(Required)

First Last Initial

Email(Required)

Confirmations will be sent

Phone

Used to schedule consultations

Which state do you live in? (Required due to State Licensing Laws)(Required)

Which services are you interested in?(Required)

Couples Counseling

Individual Partner Counseling

Pre-Marital Counseling

What is your preferred venue?(Required)

In-Person Only

Virtual Sessions Only

Either

Hybrid

Which office location in VA do you prefer?(Required)

Alexandria

Arlington

Charlottesville

Fairfax

Leesburg

McLean

Midlothian

Reston

Short Pump

Doesn't Matter (virtual only)

Which office location in MD do you prefer?(Required)

Bethesda

Columbia

Frederick

Rockville

Doesn't Matter (virtual only)

Which office location in NC do you prefer?(Required)

Cary

Charlotte

Wilmington

Doesn't Matter (virtual only)

Which office location in DC do you prefer?(Required)

Dupont Circle

Doesn't Matter (virtual only)

Which office location in FL do you prefer?(Required)

Winter Park

Doesn't Matter (virtual only)

Which office location in SC do you prefer?(Required)

Charleston

Mt. Pleasant

Doesn't Matter (virtual only)

Which office location in CA do you prefer?(Required)

Los Angeles

Santa Monica

Doesn't Matter (virtual only)

Which office location do you prefer for West Virginia Residents(Required)

Leesburg

Frederick

(Telehealth is not available for West Virginia residents)

Therapist Preference?(Required)

Specific Therapist Alexandria(Required)

Specific Therapist Arlington(Required)

Specific Therapist Charlottesville(Required)

Specific Therapist Fairfax(Required)

Specific Therapist Leesburg(Required)

Specific Therapist McLean(Required)

Specific Therapist Midlothian(Required)

Specific Therapist Reston(Required)

Specific Therapist Short Pump(Required)

Specific Therapist VA Virtual Only(Required)

Specific Therapist Washington DC(Required)

Specific Therapist DC Virtual Only(Required)

Specific Therapist Bethesda(Required)

Specific Therapist Columbia(Required)

Specific Therapist Frederick(Required)

Specific Therapist Rockville(Required)

Specific Therapist MD Virtual Only(Required)

Specific Therapist Cary(Required)

Specific Therapist Charlotte(Required)

Specific Therapist Wilmington(Required)

Specific Therapist NC Virtual Only(Required)

Specific Therapist Charleston(Required)

Specific Therapist Mt. Plesant(Required)

Specific Therapist SC Virtual Only(Required)

Specific Therapist Winter Park(Required)

Specific Therapist FL Virtual Only(Required)

Specific Therapist for WV resident (Leesburg office)(Required)

Specific Therapist for WV resident (Frederick office)(Required)

Specific Therapist Los Angeles(Required)

Specific Therapist Pasadena(Required)

Specific Therapist Santa Monica(Required)

Specific Therapist CA Virtual Only(Required)

Are you aware we are NOT "in-network" with health insurance companies and you will pay out-of-pocket for our services?(Required)

Yes, I understand I will pay out-of-pocket and some reimbursement may or may not be possible (required to finish form)

No, I'd like to learn more about your fees & insurance reimbursement policy

Please click here to visit our fees and insurance page. This should help answer your questions about costs and reimbursement options. Knowing that we do not accept in-network insurance is required before scheduling or talking with someone.

How did you hear about us?(Required)

Google search

Therapist referral

Current/Former client of ours

Social Media

Other

What is the question or phrase you typed into Google that led you to us? (No worries if you don't remember)

What is the name of the therapist?

How did you find us?

Relational Wellness

Yes, when you get time to write "relational wellness" blog posts send them to me (just not too many)

SMS Consent (optional)

By checking this box, you consent to receive text messages from Well Marriage Center regarding your inquires or services. You may opt-out at any time by replying STOP. For Assistance text, HELP. Message and data rates may apply. Messaging frequency may vary. Visit https://www.wellmarriagecenter.com/privacy-policy/ for privacy policy and Terms of Service.

Licensed, professional, therapists offering specialized couples counseling, individual therapy, and relationship wellness programs. We welcome ALL relationships!

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Marriage Counseling
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