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Collins Client Enrollment Form
If you are unable to pay the registration fee at this time, we do offer a payment plan. Do you need a payment plan?
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Email
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Your email
Phone #:
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Your answer
Name:
*
Your answer
Email Address
*
Your answer
Today's Date:
*
MM
/
DD
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YYYY
Date of Birth:
*
MM
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DD
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YYYY
Who referred you?
*
Your answer
Do you prefer zoom or in-person sessions?
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Yes
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Gender
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Prefer not to say
Male
Female
Other:
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Service Requested:
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Your answer
Address:
*
Your answer
Primary Language:
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Your answer
Days and hours of availability:
*
Your answer
If you are a Court-Mandated client, please email all court documents as an attachment to
collinscounseling2020@gmail.com
. This will allow us to see what classes were ordered by the court.
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Additional questions or comments
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A copy of your responses will be emailed to the address you provided.
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