New Client Appointment Request
Doylestown Counseling Associates, Inc.  
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Name: First and Last
Phone Number
May we text you?
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I prefer
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Briefly, why would you like to schedule an appointment? (ie., anxiety, relationship/family issues, grief, depression, work issues, etc)
Age
Date of Birth
MM
/
DD
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YYYY
Who is your employer? Who is the employer that you received insurance and/or EAP benefits? *
Insurance Company Name
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Insurance Company Member ID #
EAP (Employee Assistance Program)  If using?
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Number of EAP Sessions  if using EAP?
Which counselor (if you have a preference)?
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What is/are the best time(s) of the day for an appointment?
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Email Address
Full Address (Street, Town, Zip)
How did you hear of us?
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