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Primary Contact Information:

Participating Contact Information:

Social Media:

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Emergency Contact:


Referral Info:

Why are you specifically seeking counseling?  (Check all that apply)

Mental Disorders:

Does anyone in your family (grandparents, parents, uncles, aunts, cousins, siblings, etc.) have an official diagnosis of a mental disorder?

Comments: (Optional)

Are you taking any prescriptions medications?

Family Information:

Do you have children?

Ken-Lyn also offers “Associated Services.”  Are you seeking assistance with any of the following (Select  all that apply)?:

Military Status:

Is the client associated with the military?

Please identify any diagnosed medical or psychological/mental issues:

Please identify any addictions that you/partner/child may have

What are the best 2-3 days and times to meet with you and when would you like to start?

CANCELLATION POLICY:  Ken-Lyn has made great efforts to have the MOST AFFORDABLE, yet full time services available to all clients.  If a cancellation occurs within 24 hours of the original appointment (to give others a chance to book in the day/time slot reserved for said client), a $75 charge will be assessed. A courtesy call or text to the Ken-Lyn Offices is necessary to officially notify us of your cancellation.   

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Please continue to complete Agreement Form

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