Online Contact Form: Healing and Recovery Case Evaluation Form

Online Contact Form: Healing and Recovery Case Evaluation Form2019-01-25T10:53:13+00:00

Wish to receive services to help yourself heal and recover from the effects of a controlling group or relationship?

Please complete this form to tell us about your needs.

This form asks for a lot of information as it will help us with our initial consultation. However, please know that some clients prefer to give us the details orally. If you can give us as much detail as possible within 10 pages, please do so as it is considered part of the initial consultation. If you choose to type your responses, we ask that you use Times New Roman 12-point font. Attach additional sheets as needed. Fields marked with an asterisk * are required, please. If you wish to give us more than 10 pages, there will likely be an additional time charge.

Thank you,

Steven Hassan

Healing and Recovery Case Evaluation Form
Fields marked with an * are required

Please check the issues you are currently dealing with. Feel free to use more than one check if it is a major issue.