About     |      Services    |       Register

I am only accepting new clients through seculartherapy.org.


Your electronic signature on this Registration Page confirms that you have read and understood the Client Rights and Responsibilities, the Privacy Policy, and the Informed Consent to Treatment. Your signature also confirms that you agree with the following:

  • You agree that you are at least 18 years old or older
  • You agree that you are the person whose name appears on the registration
  • You are NOT currently suicidal or a danger to others
  • You agree to pay the fees for the services you choose

Registration

*required field
*First Name:
*Last Name:
DOB:
* Address Line 1:
Address Line 2:
* City:
* State:
* Zip:
*Telephone Number:
Alternate Telephone Number:
Best time to call:  
*E-mail Address:
Alternate E-mail address:
In case of emergency contact:
Relationship to Patient:
Emergency contact telephone number(provide a current phone number for the contact listed above)
Other provider with whom you would like me to collaborate:
Name Type of provider Address Telephone
Briefly describe your reason for seeking counseling services at this time
Please provide any other information you feel may be helpful to me in providing you services
Service options Enter number of Sessions          $0.00

By checking this box I certify that I have read and understood the Consent to Treatment, Privacy Policy, and Client Rights and Responsibilities:  


Freethought Counseling  |  E-mail: counselor@freethoughtcounseling.com
 

*To receive the free service, you will need to register. Registration is free and confidential.
In order to receive a free e-mail reply, your initial message to me should be 300 words or less. I will respond within 72 hours.