New Client Request Form
For assisting in matching you to the best clinician to meet your needs.  We will contact you regarding your request in the next 24 to 48 hours.  

This is not intended to be used for emergencies- if you are experiencing a medical or psychiatric emergency, please go to the hospital or call 911.
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Name (of person seeking treatment) *
If the potential client is a minor, who is the best contact person and their relationship to the child?
Date of Birth of Person Seeking Treatment *
**If under 18**  Is there a custody agreement in place for the minor?  (If so, we will need a copy of this so we can best accommodate your family's needs) *
Phone Number *
Your email address (by giving your email, you're stating you are comfortable with receiving emails from an address ending in *
Reason for seeking treatment *
What type of insurance do you have as your primary insurance?
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I understand that plans and benefits vary and, while Pivot Point can help assist in gathering information, I am ultimately responsible for confirming coverage with my insurance company. *
Would you like us to help with understand your insurance benefits
If you feel comfortable sharing, this helps us move along the process for you!  Please know that plans and benefits vary and while we can help assist, you are ultimately responsible for confirming coverage with your insurance company.
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This form was created inside of Pivot Point Counseling, LLC.