Please note, we do everything possible to protect this information. However, this form is not HIPAA compliant and absolute online security is not a guarantee. Please keep this in mind as you respond.
Additionally, Shannon’s waitlist is currently about 2 months out for individual therapy clients and 3 months out for couples therapy clients. Please fill out the form below if you would like to set up a consult call and be placed on her waitlist.
First Name
Email Address *
Subject
How did you find us? (Referral Source) *
Residency * I live in UtahI do not live in Utah
Desired Service Online Individual Work (weekly/biweekly for at least 3-6 months)Online Relationship Work (weekly/biweekly for at least 3-6 months)Intensive Consultation (one time meeting, in-person, 4-6 hours)
Please mark all that apply * I can make appointments during the morning or afternoon (there are no evening slots available at this time)I can schedule regular appointments during the work weekI am open to working exclusively online, via ZoomThe inability to use insurance will not interfere with my commitment (Shannon does not accept any forms of insurance)I understand that Shannon's waitlist is currently at least 2-3 months out
How would you describe the type of help you're looking for?
Consent * I offer consent to Core Healing Counseling, LLC to collect my details through this form and understand that it is not HIPAA compliant
