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 mediation please email or call.  If you are a new client seeking couples coaching, please complete the following forms and bring them to your first session.


If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of coaching information:

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.

Contact Me

Contact Us to Request an Appointment

We look forward to hearing from you

Appointment Request

Location

Availability

Phone 703-382-6871 | Fax 703-382-6872 | [email protected]

Primary

Monday:

9:00 am-8:00 pm

Tuesday:

9:00 am-8:00 pm

Wednesday:

9:00 am-8:00 pm

Thursday:

9:00 am-8:00 pm

Friday:

9:00 am-8:00 pm

Saturday:

Appointment Only

Sunday:

Closed