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New Client Inquiry
Filling out this form will assist Nurtured Counseling in better understanding your therapy needs and getting you scheduled.
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First & Last Name *
Date of Birth *
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Phone Number *
Email Address *
Which state are you located in? *
What time zone are you located in? *
How do you prefer to be contacted? *
Health Insurance Carrier (please be specific, and include if it is Commercial or Medicaid)
If you do not have health insurance or we do not currently accept your insurance, are you open to private pay?  ($130/hr)
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Which therapist would you like to work with? 
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Schedule Preferences - what days and times would be best for scheduling your sessions? *
Please share a few sentences about why you are seeking therapy services. *
How did you hear about us?
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