REQUEST FOR SERVICE

I am interested in requesting the following service from Paul R. Wuehler, Ph.D.
    Crisis Consultation Service $125.00
    Marital or Parent/Child Conflict Resolution $250.00
    Premarital Consultation $400.00
E-mail:
Age:
Gender: Male Female

Payment Information:
    
Visa/MC Number: Expiration Date: / MM/YY
Cardholder Name:

Upon receipt of the above information, Dr. Wuehler will promptly E-mail a form to complete requesting basic information regarding the circumstance. Consultation will proceed from there.