Schedule A Consultation

Name *

First Name

Last Name

Phone *

(###)

###

####

Important *

This online service is designed to schedule non-emergency appointments only. I agree I am not in danger at this time and would like to schedule an appointment. If you are in serious or foreseeable danger, please call 911 or have someone take you to the nearest hospital.

Are you 21 or older? *

Yes

No

What state do you live in? *

Massachusetts

Texas

Can we leave you a voice message? *

Yes

No

What services are you interested in? *

Therapy

Coaching

How urgent is it for you to begin? *

High

Moderate

Low

Important *

I understand this practice only provides online therapy. I understand this practice is only open Monday - Thursday, 10 AM - 6 PM. I understand weekly individual therapy is preferred. I understand this practice takes private pay (self-self). Meaning I will pay the full fee myself for each session.

Important *

I understand this practice offers a 80-minute individual counseling session at a rate of $245 and a 60-minute individual counseling session at a rate of $205. I understand that completing this form does not initiate a therapeutic relationship between myself and Comfort Nyeswah-Wiafe, LMHC, LPC. I understand this practice offers a 60-minute individual coaching session at a rate of $100 and a 30-minute individual coaching session at a rate of $50. I understand that completing this form does not initiate a coaching relationship between myself and Coach Manuel Eje.