Counseling Inquiry with JacobPlease complete this confidential form and Jacob will be in touch within 1 business day. Name * First Name Last Name Email * Phone * (###) ### #### Age * Please select range 10-14 15-17 18-25 25-30 30-40 40-50 50-60 60+ What type of therapy are you looking for? * Individual Couple Family Please describe why you are looking for counseling. * What is your prior experience with counseling? * Any other information or questions you'd like to share? Thank you!
