Appointment Request Form
Once an appointment is requested, you will receive an email from Simple Practice to give you access to your secure patient portal. Please complete the shared intake paperwork and then our intake department will call you to assign a counselor and schedule your first appointment. Thank you.
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Is this appointment request for you or someone else? *
If the appointment request is for someone else, please state your name and relationship to the client. If the client is a minor, please include your email address for portal access.
I am seeking: *
If the client is under the age of 14 or you are seeking couples counseling, please call our office to ensure availability before requesting an appointment. Thank you!  *
Required
Client's Legal First Name: *
Client's Legal Last Name:
 *
Name The Client Goes By: *
Email Address: *
Phone Number 
(this is NOT used to opt you into text messages but is required to call to schedule your first appointment).
 *
Date of Birth:
MM
/
DD
/
YYYY
If you have insurance, please include the name of your Insurance provider below. *
In-Person or Telehealth Preference: *
Clinician Request/Preference (their name, gender, race, etc.): I understand that the clinician I request may be unavailable at the time of my request or unable to accommodate my schedule.
 *
How did you hear about Cultivate Counseling & Consulting? *
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