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Doylestown Counseling Associates, Inc.  
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Name (First & Last)
Phone Number
Can we text you?
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Email Address
Briefly, why would you like to schedule an appointment? What services are you interested in? (ie., anxiety, relationship/family issues, grief, depression, work issues, couples etc)
I prefer
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Have you been hospitalized for any mental health issues within the last 6 months?
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Age
Date of Birth
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Insurance Company Name
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Insurance Company Member ID #
EAP (Employee Assistance Program)  If using?
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Number of EAP Sessions  if using EAP?
Which counselor (if you have a preference)?
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Address (Street, Town, Zip)
How did you hear of us?
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