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Request for Services
Please complete this confidential form completely and accurately so that we can serve you in a timely fashion. Thank you!
Do you plan on using insurance?
Which insurance company do you have? (Please note: We DO NOT ACCEPT MEDICAID. We only accept plans for the insurance companies listed below.)
Will you be physically bein the state of VA during the time you will be receiving services?
Are you planning to use Employment Assistance Program (EAP)?
Upload Insurance Card
Have you seen anouther counselor in the past 12 months?
Have you ever been seen by a counselor at Freedom Support Services?
Have you been screened for and/or admitted to a pyschiatric facility within the last 12 months?
If there are no openings available, would you like to be added to our waiting list?  
Do you have a preference for the gender of your counselor?
If yes, what is your preference?
Do you prefer In Person or Teleheath sessions?

Providers

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Please check ALL of the providers that you are willing to see. You can learn more about all providers by clicking the links below:

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Shaterra Walker, Licensed Professional Counselor​

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Tameesha Curry, Resident in Counseling 

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Chandra Shorter, Licensed Professional Counselor

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Lauren Rutledge, Licensed Professional Counselor

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​Pragya Agarwal, Licensed Professional Counselor

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​Katelyn Lloyd, Resident in Counseling 

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Julie Jackson, Resident in Counseling 

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Tiffany Watlington, Resident in Counseling 

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​Eleah Ruffin, Resident in Counseling 

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Counselors:

Thank you for your interest in our services. We have a high volume of requests and strive to respond to all requests for services within 2 business day. If you do not hear back from us, please send a courtesy email to clientcare@myfreedomss.com. Thank you!

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