Name *

First Name

Last Name

Inquiring about

Couples Therapy (Weekly)

Couples Retreat or Intensive

Discernment Counseling

Individual Therapy

Press/Presenting

Residence *

Washington

Montana

PSYPACT State

Please review disclaimer below and press 'submit'

I acknowledge that electronic communication, including web forms and email, is limited in terms of privacy and may be intercepted by a third party. I understand that this electronic communication does not constitute a therapeutic relationship. I hereby release Dr. Kellison from any and all liability that may occur due to electronic communication over a non-secure network.