Take The First Step

Contact me.

Jessica@mindshieldsforyou.com
(334) 315-5515

Wetumpka, AL

Name

First Name

Last Name

Child(ren)'s Name (if child will be the client). If you are an adult client, type NA.

Phone

(###)

###

####

What insurance does the potential client have?

Reason for Seeking Therapy

If this is a court case, type the names of all attorneys involved as well as the judge over the case. If this is NOT a court case, type NA.

If this is for co-parenting counseling, type the name of the other parent. If not, type NA.