Online Registration for Professional Consultation at Rainbow Counseling Center

Online Registration
for Professional Consultation

Please complete the following form and when your credentials are verified you will receive registration information and further instructions.


	Full Name:
	Address:
	City:
	State:
	Zip:
	Office Number:
	Fax Number:
	E-mail:
	Profession:	mental health professional attorney clergy
	License number /registration:
	State:
	Name of practice, business, or church affiliation:

Rainbow Counseling Center Inc.
414 E. Fifth Street, E. Liverpool, Ohio 43920
Phone: 330-386-3844 | Email: info@rainbowcounselingcenter.com