First Name
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Last Name
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Phone
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Email
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Street Address
City
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State
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How did you hear about us?
How would you like to receive services?
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In-person Only
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Open to Both/either
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If in-person, which location are you interested in?
Midland Park(main office)
Fort Lee
Rutherford
Bloomfield
Phillipsburg
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What type of service are you looking for?
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Individual Counseling
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Which counselor do you prefer?
Do you prefer a male or female counselor?
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What days and times are you available for counseling?
Email Risk Acknowledgement and Use Consent
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I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Light The Way Counseling therapists and/or office staff communicating with me via email or text message
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