Name *

First Name

Last Name

Agree to Terms of Use *

By checking the box and sending this message, you acknowledge and accept the risks of communicating your personal information via this unencrypted email and electronic messaging and wish to continue despite those risks. You also acknowledge that sending messages to the business phone number, you accept reply messaging from that number. By clicking the "Send" button, you agree to hold Fairwinds Counseling, PLLC harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.