Interested in Working with

Dr. Curtis D. Jasper?

Please complete the following questionnaire to be considered. Your answers are totally confidential and does not obligate you whatsoever.

NOTE: You must complete the questionnaire to be considered to work with Dr. Curtis D. Jasper and to receive a free, brief consultation.

Contact Us - Form

First Name

Last Name

Phone Number

How did you hear about Dr. Curtis D. Jasper?

Are you looking for One-On-One, Couples, Family or Group Counseling? (Check all that apply)

One-On-One Counseling

Couples Counseling

Family Counseling

Group Counseling

Please describe what’s currently troubling you?

How long has this been a challenge?

What have you already done to address it on your own?

What one question are you always asking yourself about resolving this issue?

How do you think I can help you with this?

As I’m sure you’ve done your research on me, why do you want to work with me in particular?

Why is it important to work with me right now on your challenges?

If things turned out better than you planned after our work together, how will your life be different in 6 months? A year? 5 years? 10 years?

Which offering are you applying for? (Check all that apply)

Counseling

Intense Psychotherapy

Coaching

Mentoring

When would you like to begin our work together?

Do you have a history of mental illness, depression, anxiety, PTSD, physical, mental, emotional or sexual abuse? If so, please share the medical, healing, therapeutic or energetic work you've done to address this and how it is impacting your life right now. (If this doesn't apply to you, please type NA):

Participation in any of the Concierge Counseling Solution programs requires a financial investment in yourself. Please select the statement below that best describes your current level of willingness and ability to make an investment in yourself with a focus on getting results. (Your answer to this question doesn't obligate you to anything or rule you out of anything and if we mutually decide to work together, a few different programs are available):

Is there anything else you'd like me to know?