Name of person needing services:

First Name *

Last Name *

Email *

Phone *

Tell us about what you are needing help with *

How did you hear about us? *

I understand that communications via SMS and email over the internet are not secure. Although it is unlikely, there is a possibility that information I include in an email can be intercepted and read by other parties besides the person to whom it is addressed. I also understand that Reach Counseling staff will coordinate our initial phone consult, in which I permit to leave me a message at the phone number and email address provided.