New Client Request
If you are currently experiencing a mental health crisis, please DO NOT submit this form. Call your local crisis center or go to your nearest emergency room.
I would like to schedule: *
Name of Person Seeking Services *
First and Last Name
How to Contact *
Please enter your email address and/or phone number below. Be careful and check for typos!
Health Insurance *
Required
Preferred Clinician *
Please select all options that you are willing to consider. Multiple selections are allowed and encouraged. The more flexible you are, the quicker we will be able to find a match for you.
Required
Availability
Our clinicians do not work evenings or weekends. Our business hours are 8a-5p. Please select all appointment times that might work for you. Please note the time ranges are the START times for appointments.
Monday *
Required
Tuesday *
Required
Wednesday *
Required
Thursday *
Required
Friday *
Required
By submitting this form, I authorize Bull City Counseling, PLLC to reach out via email and/or phone when scheduling options become available. I understand that I can edit my responses and remove myself from this waitlist at anytime. I understand this form does not guarantee scheduling and I will seek immediate mental health care if an emergency arises.
Submit
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