flfti

Fuller Life Inquiry Form

Please complete the following SECURE form to request more information from Fuller Life Family Therapy.
One of our therapists will get back to you as soon as possible.

First Name*

Last Name*

Phone*

Email*

*Please select the following that apply:

I am interested in individual therapy I am interested in couples or family therapy I am interested in therapy for my child or adolescent I would like to know what therapy would cost I would like more information I would like to partner with Fuller Life

You have indicated you would like to know what therapy would cost. Our associate therapists see clients on a sliding scale from $15 to $95 per session. The session fee is based on household income and the number of people in your home. To help us determine your fee please answer the following questions. (This site is fully encrypted and your information will be kept secure). Please choose your annual household income:

Annual income is less than $21,000 between $21,000 and $39,000 between $ 39,000 and $49,000 between $50,000 and & 60,000 between $60,000 and $75,000 between $75,000 and $95,000 More than 95,000

Please list the number of people in your home. Our therapists will contact you as soon as possible to answer any questions and discuss the fee for therapy.

You have indicated an interest in couples or family therapy. Please enter your family member or spouse’s information.

Spouse Name:

Spouse Phone:

Spouse Email:

You have indicated a interest in therapy for your child or adolescent. When working with children under age 18, our therapists will do the first session with the parents and/or guardians. Please enter the following information about your child or adolescent:

Name:

Age:

Concern:

Please check any of the following:

I would like to receive email from Fuller Life Family Therapy with resources for emotional and relational wellbeing I would like to receive email related to my inquiry I would like to receive SECURE encrypted email related to my inquiry I do not wish to receive email

Comment or Questions:

Thank you for contacting Fuller Life Family Therapy. We are honored that you would reach out to us at this time. One of our therapists will contact you within 24-48 hours to answer any questions you may have.
To contact someone more immediately call us at 855-245-LIFE (5433).