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Full Name
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Phone
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Address
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City
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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
Couples
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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)
Are you interested in a neurodivergence assessment?
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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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Phone
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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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