Name *

First Name

Last Name

Phone *

(###)

###

####

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Powerful Alternatives Counseling & Consulting, LLC harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Yes, I want to submit this form & agree to the terms of use. *