Client Portal - Untanglife Counseling PLLC

Appointment Request

Thank you for contacting Untanglife Counseling PLLC. Please fill out the information below to request your first appointment.

Personal Information:

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Middle Name:

Last Name:*

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Contact Information

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Please explain the reason you are seeking help at this time.

Your Information is confidential. However, if you are uncomfortable fully describing your reasons for seeking services, please provide enough information so our staff can match you with the appropriate provider.

If you are experiencing a life threatening emergency, do not wait for a clinician to respond to your request. Report immediately to your nearest emergency room, or call 911

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Please explain the reason you are seeking help at this time:

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