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Full Name
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Phone
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Address
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Email
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Are You Currently Seeing a Therapist/Counselor?
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Desired Type Of Counseling Retreat
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What type of counseling retreat are you interested in?
Individual
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Are you interested in a single retreat (1 person) or double retreat (2 people)?
Single Retreat (1 person)
Double Retreat (2 people)
What therapist are you interested in working with?
Dr. Kathleen Kelly
Dr. Termary Hernández
Sandy Waite
Fae Foster
No preference - Earliest available
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Scheduling Your Counseling Retreat
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Briefly Describe The Issue You Would Like to Work On
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What Is the Best Way To Contact You?
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How Did You Hear About Us?
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Email & Text Message Risk Acknowledgement and Use Consent
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I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Syrona Counseling Retreat therapists and/or office staff communicating with me via email or text message
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