New Client Pre-registration
To schedule a non-emergency appointment, or obtain additional information about any of our counseling services, please complete the form below. Completion of this form does not guarantee an appointment.

Our intake coordinator is typically available during the week between 9am and 3pm and will contact you within 48 business hours to confirm receipt of your information. We find most new clients prefer email, however, if you prefer a phone call please indicate below.

If you have an emergency, or are in crisis, please contact 911 immediately; or go to your nearest hospital's emergency department.

Name *
Your answer
Email *
Your answer
Phone Number *
Your answer
Main Reason For Scheduling *
Your answer
Type of Appointment
Insurance Company
What days work best, check all that apply *
What times of day work best, check all that apply *
Which office locations work for you, check all that apply
Preferred method of contact *
Additional information you would like to add
Your answer
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