Counseling Interest Form Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone *Email *Date of Birth (MM/DD/YYYY) *I want to work on *AnxietyPanicDepressionStressLife TransitionAngerGrief and LossSelf-esteemRelationship issuesCareerPaymentPrivate Pay ($120/ 50 minute)Blue Cross / Blue Shield (PPO plans only)United/OptumMessage (optional)NameSubmit