The Owen Center Personal Profile Form

  • Counseling Agreement

  • Before you enter your information, please take a moment to view the counseling agreement. To read over the agreement CLICK HERE. By selecting "Yes" in the following question, you acknowledge that you have read over and agree with the Counseling Agreement. If you have any questions about this, please call our office or email us at
  • - You understand the counseling agreement. - Your counselor is obligated by state law to report any incidents of suspected or obvious child abuse or neglect. - Your counselor may ask your permission for another counselor/perspective counselor to sit in a session. - Your counselor might be required to divulge information to appropriate civil authorities if there is an indication that you or someone else might otherwise be harmed or be at risk of abuse or neglect.
  • Personal Information

  • MM slash DD slash YYYY
  • "___ of ___ children"
  • Marriage and Family History (If Applicable)

  • We ask that those we counsel invest in their own counseling by donating to the Center according to ability. The scale below suggests the appropriate investment according to your Family Annual Income and the expected Investment per hour: $0-$12k/$25 per hour; $13k-$24k/$40 per hour; $25k-$40k/$50 per hour; $41k-$55k/$60 per hour; $56k-70k/$80 per hour; $71k-$85k/$90 per hour; $86k and up/$100 per hour.
  • This field is for validation purposes and should be left unchanged.