Request an Appointment

Name*

First Last

Phone*

Do you prefer we text you?*

We can text instead of calling or emailing to schedule your appointment, if you prefer.

Yes
No

Email Address*

I'm looking for:*

Individual Counseling (for myself)
Relationship Counseling (for myself and my partner)
Counseling for my Child (below 13)
Counseling for my Teenager (13-17)
I'm not sure. I need to talk to you about it first.

If you're comfortable, please briefly describe why you're seeking an appointment at Revive Wellness. This will help us make sure you're able to get scheduled with the right counselor.

At which office do you prefer to be seen?*

Which counselor do you prefer?*

No Preference
Kansas Corley
Sheena Barfield

Which counselor do you prefer?*

No Preference
Justin Walker

Which counselor do you prefer?*

What time of day works best for your schedule?

Please select all that apply.

I'm flexible. Please give me the first available appointment.
Early Morning
Daytime Hours
Afternoon
Evening
Weekend

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Appointment Request