Appointment Request
To request an appointment you can call 585-398-8835 or use this form below. Please allow one business day to get back to you.

Please note: This form is not for current clients. Current clients please call 585-398-8835 or email hello@victorcounseling.com to change/reschedule appointments.
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Client's full name
Client's date of birth
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If you have a specific clinician you are seeing or would like to see, please put their name here
Contact Name (if different than client)
Contact Phone number
Please format with dashes e.g. 555-555-5555
Contact Email *
If you are using insurance to pay for any portion of services, please indicate below.
NOTE: We do not take "Medicare Primary"
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Subscriber ID of your insurance
Do you have a preference for an in-office or telehealth appointment? Or a mix?
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Which office would you prefer to see your therapist?
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Preferred appointment day of the week and time of day?
To help us match you with the right therapist, please let us know if you are experiencing any of the below (select all that apply)
NOTE: If you are experiencing suicidal thoughts or are in a life threatening situation, please call 911 or go to the nearest emergency room immediately.
Please provide us with any other information you believe would be helpful
How did you hear about Renew Hope and Healing?
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