E-mail Counseling Form

E-Mail Counseling
at the Family Counseling Center

Thank you for your interest in our Online Counseling services.

We offer email counseling to enable you to ask your personal questions to a qualified professional through the unique convenience of the web. Email counseling offers you the opportunity to get advice on your own time. You do not need to make an appointment. Nor do you have to go anywhere. You are offered the convenience of counseling in your own home on your own time. Please note that if you choose to receive your email counseling through an email you use at your office, your emails may not be confidential, because business and security practices vary from office to office.

While every question will be seriously addressed, it's important to note that email counseling does not offer some of the interpersonal advantages of a face-to-face session with a therapist. If we feel your situation deems face-to-face counseling, we will make that recommendation.

PROCEDURE
If you want email counseling, we ask that you complete the form below. It is important that you answer every question.

We will NOT bill your credit card until we have assessed that we can actually help you.

After we have accepted you as a client, we will bill your credit card for $15.00 and respond to your question/problem. $15 is good for one (1) email question. If you need to send us more information than you can give us on this form, we will make arrangements for your to do so at no additional charge.

SECURITY -- This is a secured (encrypted) form. Please make sure you have a "lock" icon at the bottom of your screen to comfirm this secured status. DO NOT send this form if you do not see the "lock" icon at the bottom of your screen. Instead, please contact our webmaster about the problem.

Name:
Address:
City, State:
ZIP:
Phone (xxx-xxx-xxxx):
Email:
Age:
Sex:	Male Female
What is your question or problem? If you need to give more information than you can type here, we will give you an opportunity to send us further information.
All credit card information is confidential. Click here to view our PRIVACY POLICY. You will not be billed until we have reviewed your form and accepted your case.
I will pay by credit card ONLINE. I will pay by credit card over the PHONE. I will MAIL my payment to you.
Credit Card:	Mastercard Visa
Number:
Expiration:	Month: Year:
SUBMIT: By pressing the submit button below, you agree that you have requested email counseling from the Family Counseling Center Association and, if you checked "I will pay by credit card ONLINE", you agree to have the above referenced credit card charged the amount of $15 for one email counseling session. If you have chosen to pay over the phone or by mail, we will give your our address and phone number upon submission of this form. You understand that you will not be charged if, after reviewing your form, we decide we are unable to help you.

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Family Counseling Center Association
2401 Oakland Blvd., Suite 100
Fort Worth, Texas 76103
Tel: (817) 534-2189
email: info@family-counseling.org

FAMILY COUNSELING CENTER ASSOCIATION