New Client Inquiry Form
Please complete the contact information below if you are interested in services. 

**Any submissions for an ADULT must be completed by the individual adult themselves or we CANNOT follow up on the inquiry**

Upon submitting you will receive a confirmation email from our Care Coordinator. Please check your SPAM folder if you do not receive the email within 1-2 business days.

If you are needing immediate care/services, you can find Emergency and crisis resources on our website page: https://legendarycounseling.com/emergency-crisis/
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Which of the following therapy services are you seeking? *
Required
Prospective Client First & Last Name (and Pronouns) *
 *(if you are seeking therapy for your child or teen under 18 years old - their name and Pronouns)
Date of Birth: *
*(If applying for a dependent under 18 years old, their date of birth)
Parent / Guardian Full Name (and pronouns):
(If you are applying for a minor, please detail the custody arrangement for the child's care, and how you are related)
Email Address: *
Street Address City, State Zip Code: *
Phone Number: *
How do you prefer to be contacted? *
Required
How did you hear about us? *
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