Please complete the information form to the right.    

We serve patients that reside in Virginia, Florida or Hawaii.

Fields with astericks (*) are mandatory.

You have the option of two locations (Mechanicsville & King William, Virginia) or we also offer virtual consultations.    

After you submit your form, you will receive a welcome Email and we will review your information.  

Once all your information is verified by our staff, we will place you on the Wait List or reach out to verify anything that is missing.

In the event of late cancellation, charges will apply.    

We can be reached for any questions or concerns at  (804) 398-8401 

  Our business hours are 8:30 AM - 5:00 PM Monday through Friday.    

Old Towne Counseling Services

Welcome to our Registration Form. Thanks for your assistance. We will be able to review and process your request as quickly as possible after receiving the form.

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