Goodbye

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Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Who is your counselor?(Required)

How would you rate your experience with MyCounselor?(Required)

5-Star4-Star3-Star2-Star1-Star

Are you interested in a FREE session to try a different counselor?(Required)

Yes!

We want to help you reach your goals. No counselor is a perfect fit for everyone. If you haven’t reached your goals yet we’d like to offer you a free session with a different counselor.

Awesome!

Press submit and our Member Support team will contact you to help you match with a new counselor for your free session. Your memberships will continue for now. If it does not work out, you can still cancel your membership at any time by completing this form again.

Did you achieve one or more of your goals for counseling?(Required)

Yes

On a scale of 0 to 10, how likely are you to recommend MyCounselor.Online to a friend or family member?(Required)

0	1	2	3	4	5	6	7	8	9	10

We'd love to hear about your experience and how you think we can improve.

I would like to…(Required)

Cancel my membership, BUT continue services as a non-member.

Cancel my membership, AND discontinue services.

Future Sessions(Required)

How would you like us to handle any future sessions you already have scheduled?

Cancel all scheduled upcoming sessions.

I plan to attend all upcoming sessions. *Please do NOT cancel my upcoming sessions.*

I understand…(Required)

– All charges prior to my cancellation are non-refundable.

– My spot on my counselor’s caseload will be filled and I may have to go on a waiting list or work with another counselor if I resume my membership.

– I have 12 months after cancellation to use any remaining session credits on my account; after that they will be donated to a scholarship fund for pastors, missionaries, and foster parents.

I understand.

Goodbye

Thanks for letting us be a part of your journey!

Cancellation Form

Awesome!