Pierian Spring Counseling Request From

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- All prospective clients must be age 18+

- Clients must reside in the state of Georgia AND be present in the state of Georgia during the time of sessions

- Please only complete this form if you are the individual requesting services or a legal guardian of the minor you are requesting services for

Name of person completing form *

Age of Client *

Adult (age 18+)

Minor (age 14-17)

Name of client (if seeking services for a minor)

DOB of Client *

YYYY

Phone number *

Email *

Address *

Financial/Primary Insurance *

Insurance Policy Number (Write self-pay if applicable) *

Does client have secondary insurance? If so, what is it? *

Presenting Concern (ex: Depression, Anxiety, etc ) *

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