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*EmailPhoneText Reason for seeking counseling: Prior treatment: Type of treatment desired:FamilyIndividualMaritalCoupleOther 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: – Dr. Heather Evans: $140/session– Laura Rush: $120/session– Angelina Moncoeur: $120/session– Kaitlyn Zellner: $120/session– Paul Bauer: $120/session– William Yaich: $100/session– Lynae Martinez: $100/session– Susanna Carpenter: $40/session Questions or concerns, call 610-282-5735 or email lynne4evanscounseling@gmail.com Submit