Request for Consultation Form

Thank you for your interest in our mental health services. Please fill out the form below to request a consultation. We will contact you shortly to discuss your needs.

First name

Last name

Email

Phone

Preferred Method of Contact

Call

Text

Email

State of residence

Florida

Georgia

North Carolina

How did you learn about our services?

Insurance

Please briefly describe the reason you are seeking a consultation with our mental health therapist and any specific concerns or questions you have.

By submitting this form, I acknowledge that I am requesting a consultation with a mental health therapist at Inspired Counseling Center, LLC and consent to the use of the information provided for scheduling and communication purposes.