Client information request for SoCo Counseling, LLC
Please complete information to be added to our wait-list or for insurance verification.  
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Email *
First and Last name of client *
Client date of birth *
First and Last name of parent
Are you committed to doing weekly sessions in order to get the best results from therapy?  *
Client phone number *
Parent phone number
client email
parent email
what is your insurance plan name? *
what is your insurance plan number? *
are you willing to do self-pay if we do not take your insurance?  each session is $160.  Your insurance may have out-of-network benefits. Please contact your insurance company. *
if using insurance, do you have a deductible? *
if using insurance, do you need pre-authorization? *
Are you willing to have a daytime appointment? *
Do you prefer virtual or in-person appointments? *
What is the main concern or focus you are wishing to address in therapy? *
Do you have any other questions or concerns?
Preferred time of appointment  *
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