Use this form to get started.
Please be sure to complete the entire form and
provide a valid email so I may respond to your inquiry.

When you're finished, simply click the “Submit” button below. After reviewing your request and determining that I can be of service to you, I will email you with possible appointment dates. When we agree on a time, I will email you an invoice payable online by credit/debit card. As soon as payment is received, you will be emailed the number to call for our session.

First Name:

Last Name:

Your Email Address:

Your Telephone Number:

Briefly explain your primary issue:

Have you had counseling? Yes No
If yes, what was the result?

What would you like our result to be?

Are you interested in a spiritual approach to therapy? Yes No

I give homework to help you practice new behaviors--assignments will be specially designed for you to provide real life experience in creating your dream relationships.

Are you willing to do homework between sessions to the
best of your ability? Yes No

Important--please read carefully: Effective counseling requires you
to look honestly at issues that may be painful. You may have
uncomfortable feelings before you feel more happiness.

Do you accept that unpleasant feelings may arise after examining
difficult issues and agree to work through these feelings with
me in session? Yes No

Your personal information will be kept confidential.

Advisory:
The USA National Crisis Hotline 800-273-8255 is available 24/7
The Hawaii Crisis Hotline 800-753-6879 is available 24/7
Silent Unity Prayer Line 800-669-7729 is available 24/7
International Silent Unity Prayer Line 01-816-969-2000