Just-Between-Us ~ Online Counseling for Relationship Issues

Counseling Information Form Please fill out the following form to register with Just-Between-Us. Once you have registered and logged in, you may schedule a session. During that time you will be asked to state your question / concern. All information that you provide is confidential and will only be shared with your counselor. Please see terms and conditions for more information. All fields are required.
First Name
Last Name
Date of Birth	(example: 08/20/1962)
Email Please enter college email address to receive student discount
Password	5-7 characters
Confirm Password
Phone
Address
City
State
Zip Code

Are you currently employed/student?
How many changes in your place of employment have occurred over the past 5 years?
How many changes in your place of residence have occurred over the past 5 years?
Are you currently receiving care from a mental health professional (psychotherapist, psychiatrist, or psychologist)?
Have you had prior counseling?
Do you have a family history of mental illness or substance abuse?
Have you ever attempted suicide or had a plan to harm yourself?
Have you ever been sexually or physically abused?
Do you have sleep difficulties?
Briefly describe any medical history you feel is affecting your well being.
How did you hear About Us?

Please Check this box to accept the terms and conditions outlined above.

Counseling Information Form