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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Full Legal Name *
Preferred Name & Pronouns *
Email Address *
Phone Number *
Preferred Method of Contact *
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What type(s) of therapy are you interested in? *
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Please provide a brief description of what you are needing support with. *
Please select your preferred time(s) to meet... *
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Location Preference *
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My insurance or billing preference is... *
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Scheduling *
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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?
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Any Additional Information You Would Like Us To Know..
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