Welcome to the Client Connection Form!

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This form helps us learn more about your needs and preferences so we can connect you to the services and support offered by Metanoia Counseling and The Metanoia Healing Initiative. Please provide your contact information and answer a few questions to help us better understand how we can assist you.

Our team will follow up with you shortly to provide more details, answer any questions, and help you take the next step on your healing journey. Thank you for trusting us to support you!

Email *

Name *

Phone Number *

Preferred method of contact *

Phone Call

Text Message

What type of support are you looking for? (Please select all that apply) *

Individual Counseling

Family Counseling

Couples Counseling

Group Therapy

Holistic Services (e.g., Biomat, Aromatherapy, Myocalm)

Movement Services

Other:

Required

Do you prefer in-person, virtual, or hybrid services? *

In Person

Virtual

Hybrid (both in person and virtual)

What time of day works best for you to receive these services? (Please select all that apply) *

Morning

Afternoon

Evening

Weekends

Required

Do you currently have medical insurance?

Yes

Clear selection

If yes, what type of insurance do you have?

Are you interested in learning about our membership options? *

Yes

Maybe

Is there anything else you’d like us to know about your needs, provider preferences, or how we can support you? (e.g., gender, bilingual, specific modalities, etc.)

Submit

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