Welcome to Evans Counseling Services! Please fill out the form below and let us know if you have any questions. Full Name:* Email:* Today’s Date:* Date of Birth:* Cell Phone: Home Phone:* Address:* City/State/Zip:* Gender:* Status:*SingleMarriedSeparatedDivorcedMinor Referred by: May we leave a message?*YesNo Preferred mode of contact*EmailPhone Reason for seeking counseling: Prior treatment: Type of treatment desired:FamilyIndividualMaritalCoupleOther Availability:AMPMBoth Who else will be expected to be included in sessions? Provide name, relation, age, etc Emergency Contact Information: Contact Name:* Relationship to Client:* Contact Phone Number:* Insurance Information: Insurance Company: Name of Insured & Date of Birth: Relation to Patient: Policy/ID Number: Group Number: Co-pay/Co-Insurance: Current Deductible: Private Pay Fee, if not insured with an in-network insurance company (effective Jan. 1, 2026): – Dr. Heather Evans: $150/session – Dr. Alycha Boehm: $150/session– Laura Rush: $130/session– Angelina Moncoeur: $130/session– Kaitlyn Zellner: $130/session– Paul Bauer: $130/session– Carol King: $130/session– Sarah Falkson: $130/session– William Yaich: $120/session– Christine Wargo: $120/session– Hannah Hegedus: $120/session– Susanna Carpenter: $110/session Questions or concerns, call 610-282-5735 or email [email protected] Submit