CONFIDENTIAL APPLICATION

To arrange a no cost telephone consultation with Ann, complete this Confidential Application for Counseling. You will be contacted personally by Ann to discuss your issues and needs within 24 hours (Holidays and weekends are of course excluded).

During that 30 minute session, you and Ann will discuss your issue. If appropriate, Ann will determine the best approach to establishing counseling and a workable counseling schedule for you and your partner. There is no obligation or cost involved. The information you provide will not be revealed to ANYONE without your consent.

If you wish to make an appointment to speak with Ann in person, simply call Ann directly at 760-580-7708.

Each field must be completed -- Thank you.

Age

Name

Street Address

City, State, and Zip Code

Marital Status

Occupation

Spouse's Name

Spouse's Occupation

Best Day To Reach You

Best Time To Call You

Your Email Address

Briefly Describe Why You Want Counseling With Ann

IF YOU WERE REFERRED BY A PASTOR PLEASE COMPLETE THESE FIELDS

Ann will not contact your pastor without your specific authorization and under no circumstances before you and she have talked about possible counseling. If you set up a counseling schedule and wish to receive a 25% pastor's referral discount, you will have to approve Ann speaking with your pastor.

Pastor's Name

Church Name

Contact Phone

ANN LANDERS
Licensed Marriage Family Therapist
760-580-7708
Ann@TalkWithAnn.com