Appointment Request
This appointment request will be sent to our General Mailbox. If you know which counselor you would like to request, you will receive a faster response by submitting an appointment request directly from that counselor's profile page on our website. Upon submission of this form, a member of our clinical team will reach out within 24-48 hours for a phone consultation and scheduling.
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Email *
Location Preference
Counselor Preference *
First and Last name of person completing this form: *
Phone number of person completing this form: *
Relationship to client: *
Client first and last name (if different from person completing this form):
Client date of birth *
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Have you seen another mental health provider for an intake in the last 180 days (6 months) including a Mental Health Counselor, Psychologist, and/or a Psychiatrist/PA/NP? *
Please provide a brief description of your counseling needs: *
What are you looking for in a counselor? *
How did you hear about our practice, or who may we thank for sending a referral to us?
 *
If this appointment request is for couples therapy, please list your partner's First and Last Name, Date of Birth, Email Address, and Phone Number below. PLEASE NOTE: They will not be contacted until we have completed phone consultation/scheduling with you.
If this appointment request is for family therapy, please list below the following for every family member age 18+ who will be participating: First and Last Name, Date of Birth, Email Address, and Phone Number. PLEASE NOTE: They will not be contacted until we have completed phone consultation/scheduling with you.
If this appointment request is for a minor client (under age 18) who is a child of separated/divorced parents in which both parents must consent to services, please list the First and Last Name, Date of Birth, Email address, and Phone Number of other parent. PLEASE NOTE: They will not be contacted until we have completed phone consultation/scheduling with you.
Are you seeking services related to a workers’ compensation case or an automobile accident (including documentation for legal purposes)?
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The insurance companies below are the ones with which we are considered IN-NETWORK. Please specify which insurance company below covers your mental health benefits. If you have a different insurance provider other than these or are uninsured, please choose "None of the above/Self-Pay." PLEASE REFERENCE THE BACK OF YOUR INSURANCE CARD WHEN ANSWERING THIS QUESTION, as your mental/behavioral health benefits may be outsourced to an insurance company that differs from the one that manages your health benefits. PLEASE NOTE: Couples Counseling, Family Counseling, and Biblical Counseling are considered "self-pay" services, as they are not billable to insurance. See our FAQ for Couples and Family Counseling for more information. *
If you are not the primary policy holder, please list the primary policy holder's first/last name, their date of birth, their relationship to you, and their address (if different from yours)
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