Contact Information Form
Thank you for your interest in New Perceptions Counseling, PLLC!

Please fill out the form below. If your requested therapist is available, they will contact you directly. If you are unsure which therapist to choose, or if your selected therapist is unavailable, the Practice Coordinator will contact you to discuss other options.


Are you looking for one of our group offerings? Click the link below to fill out the form for the group you are interested in joining and we will reach out shortly.


*This form is located on a HIPAA-compliant drive and all information is stored securely.
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Legal Full Name *
Preferred Name & Pronouns *
Email Address *
Phone Number *
What type(s) of therapy are you interested in? *
Required
Please provide a brief description of what you are needing support with. *
When are you available for sessions? (please select all that apply)
Morning
Afternoon
Evening
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Location Preference *
Required
My insurance or billing preference is... *
Required
Scheduling *
Required
If you have a preference for the therapist(s) you prefer to work with, please let us know. We will do our best to accommodate your request.
How did you hear about us? (If referred, please share who referred you)
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