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Counseling Inquiry Form
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Date of birth
Phone number (###-###-####)
Please tell us in a a few words; What brings you to counseling and Who will be participating in the sessions (self, couple, family, kids).
What type of therapy are you interested in? (check all that apply)
Therapist you'd like to work with
Help me choose
Appointment time preference; Day and Time (Office hours are M-F 8am to 6pm; Some Therapists have availability outside these hours)
Therapy Location Preference
In Person at PCC office
Please let us know if you are wanting to use insurance, by selecting one of the participating providers below.
If we are not in Network with your insurance provider, are you interested in private pay? (we can provide a superbill for you to submit for out of network)
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