Name *

First Name

Last Name

Partner's Name

First Name

Last Name

Phone Number *

(###)

###

####

What would you like to address in counseling? *

You may choose as many options as apply.

Communication Difficulties

Difficult Childhood

High Conflict

Infidelity

Financial Concerns

Intimacy

Parenting

Careers

Emotional Abuse

Domestic Violence

Substance Abuse/Addiction

Trauma/PTSD

Workshop: Bringing Baby Home

Workshop: Transition to Parenthood

Workshop: Making the Magic Last

Other

Notice Regarding Email Communication *

This form will be submitted to the office of Janie McMahan, MA, LMFT via email message. Email is a convenient form of communication, but confidentiality of the information submitted cannot be guaranteed due to email providers storing information on their servers. It is possible that your form submission could be viewed by a third party. By submitting this form, you are acknowledging the risk, however unlikely, that may be involved in submitting this form.

I have read the statement above regarding submission of this form and acknowledge and agree to its contents.