Forms

To schedule a mediation, individual, couples coaching appointment or to obtain additional information about any of these services, please fill out the form below or give me a call.  Please note that The Path to Well-Being office will remain open and are accepting new clients. We are also able to offer telehealth or online mediation & counseling or online service options to those who would prefer to access services remotely. Please contact the office for further information.  

If you're a new client seeking negotiation or mediation services please email or call.  

If you are a new client seeking couples coaching, please complete the following forms.

• Client Coaching  Intake Form
• Limits of Confidentiality/Coaching Policy
• Cancellation Form

• Authorization to Disclose Information Form

Note: To fill and sign these documents, please download Adobe Acrobat Reader for free, as they have a Fill & Sign option. Click here. Completed documents can be uploaded via the Contact form below. You can also email the forms directly to [email protected].

Proudly Serving:

Proudly Serving: Bristow, Chantilly, Herndon, Reston, Centreville, Fairfax, Springfield, Vienna, Tysons Corner, Fair Oaks, Gainesville, Haymarket, Manassas, Fredericksburg, Winchester, Middleburg, Woodbridge, Dumfries, Oakton, Falls Church, McLean, Sterling, Front Royal, Leesburg, Quantico, Stafford, Fredericksburg, Culpeper, Dulles, Brambleton, South Riding, Arlington, Annandale, Warrenton, Marshall, Bealton, Dunn Loring, Great Falls, Merrifield, Lees Corner, Oak Hill, Manassas Park, Manassas City, Fauquier County, Culpeper County, Rappahannock County, Prince William County, Fairfax County, Stafford County, Spotsylvania County, Frederick County, Loudoun County, Clarke County, Orange County, Alexandria, Washington D.C. and Surrounding Areas. Specialize In Veterans and their Families,  Digital/online  Available Please call 703-382-6871 or email for a free mini individual consultation by phone or telehealth/online!

To schedule an appointment, paperwork should be emailed in advance.  A confirmation email with acceptance of date 

requested will be sent to confirm appointment.

To provide excellent service to all our clients and the best possible environment, our policy requires a fee for no-show appointments and cancellations made less than 48 hours before the scheduled appointment. Monday appointments need to be cancelled by Thursday. 

During inclement weather appointments will be provided on-line.