REQUEST AN APPOINTMENT FORM
Welcome to Blue Boat Counseling! We're happy you're here. In order to request an appointment, we ask that you please answer the following questions as they relate to the client who will be seen. Then someone will be in touch very soon to discuss scheduling options for your first appointment.

**Please note that in the interest of the health and safety of our clients and staff, we are still only offering online therapy due to the COVID-19 pandemic. If you'd like more information about online therapy, you can read more on our website here: https://blueboatcounseling.com/online-therapy/.
Your name (or name of the client to be seen) *
Your name and relation to the client (if you are not the one to be seen)
Mailing address *
City *
Zip code *
Phone number *
May we send you text messages related to our practice and scheduling? *
Email address *
May we send you emails related to our practice and scheduling? *
Gender *
Date of birth *
MM
/
DD
/
YYYY
Is there a specific therapist you're requesting? *
What type of counseling are you looking for? *
What primary concern are you seeking treatment for? *
Is there anything else we should know before scheduling your first appointment?
Please note your understanding of the following: After careful consideration, Blue Boat Counseling has chosen to be an OUT-OF-NETWORK PROVIDER with insurance companies and cannot bill them directly on your behalf, but you can choose to receive a billing statement to submit to your insurance for possible reimbursement, depending on your plan's coverage. The full fee is due at the time of your appointment, and HSA/FSA cards are accepted options for payment. You can read more here: https://blueboatcounseling.com/fees/ *
Please tell us how you heard about us. *
Thank your for your responses. Someone from our team will contact you to schedule. We look forward to being a part of your counseling journey.
Submit
Never submit passwords through Google Forms.
This form was created inside of blueboatcounseling.com. Report Abuse