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Preferred Therapist*
—Please choose an option—Masuma Rasheed, PhDAlex Ngo, LCSWMalarie Marquez, LPCNoah-Christina Reed, LPCDeKhari Dixon, MAErika Chavez, LSWLuz Maria Miranda, LPCTiffani Clay, LPCSophia Ou, LPCSylvia Chen, LSWNo Preference

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I acknowledge that I am seeking services while in the state of Illinois.

Acknowledgment: Telehealth Services*
I acknowledge that Mindful Life Counseling provides services exclusively through telehealth. I understand that all sessions will be conducted remotely, using telecommunications technology, and I consent to receiving services in this format.

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