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FREE 15-MINUTE CONSULTATION

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Free Consultation

We provide complimentary 15-minute consultations to explore your needs. Simply fill out this form and we will get back to you asap. If you would like us to verify your insurance before giving you a call, please fill out the insurance information.

If this is an emergency or you are experiencing a mental health or substance use crisis, please call/text 9-1-1 or 9-8-8.

Consultation Form

First Name

Last Name

Date of Birth * required

Email

Phone

Full Address

Insurance Provider

Insurance Member ID

Subscriber Name (If Different from Patient)

Subscriber DOB (If Dependent)

Do You Have A Preferred Counselor?

Yes (Please let us know which you prefer)

No Preference

If you answered "Yes" to the previous question, please enter your preferred counselor's name.

Area(s) of Concern (choose all that apply) * Required

Anger Management

Anxiety

Behavioral Issues

Bipolar Disorder

Domestic Abuse

Depression

EMDR Therapy

Family Conflict

Marriage Counseling

Mood Disorder

Obsessive Compulsive Disorder (OCD)

Oppositional Defiant Disorder (OCD)

Post Traumatic Stress Disorder (PTSD)

Relationship Issues

Self Esteem

Sexual Abuse

Sexual Issues

Sleep Issues or Insomnia

Suicidal Ideation

Teen Violence and Bullying

Patient Needs

How did you hear about us? * Required

Search Engine (Google, Bing, etc)

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Psychology Today

Referral (please tell us who)

If you selected referral, please tell us who referred you.

Thank you for reaching out. Your request is confidential and deeply appreciated. A licensed therapist or staff member will be in touch with you shortly.

Online Counseling

Secure and Private Therapy Throughout Virginia

Administrative Office

Manassas Office

10391 Greyson Ln

Rixeyville, VA 22737-1730

9255 Center St, Suite 203

Manassas, VA 20110

info@evergreenbehavioralhs.com

©2025 by Evergereen Behavioral Health Services, LLC

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