New Client Appointment Request
Please complete the form below and click submit to request an appointment with an associate of The Center for Relationships Team. If you are unsure of who would be a good fit for your needs, our intake coordinator will be happy to:

Please give us the information that you think will help us provide the best services for you. Your data will be transmitted and stored securely in our Google for Work site which is encrypted and HIPAA compliant.

Client Name (First and Last) *
Your answer
Contact Phone Number *
Your answer
Have you received services previously at The Center for Relationships? *
Client Email Address (will be used for scheduling) *
We use the email address to set up your secure account on our records system and may be used for reminders of appointments, scheduling or billing questions. We do not ever share your email or other information with third parties without your express written permission.
Your answer
Who is this appointment for? *
Please choose the one option that best describes your request. If you choose other, please fill in response.
Date of Birth *
Your answer
Phone *
Your answer
Street Address *
Your answer
Address Line 2 *
Your answer
City *
Your answer
Zip Code *
Your answer
Emergency Contact with Name, Phone, Relationship *
Your answer
How did you hear about us? *
What are your best times for an appointment (morning, afternoon, evening, days of the week, etc) *
Your answer
Do you have a particular associate at the center that you would like to meet with? *
You may read about our team on our website: http://www.thecenter4relationships.com If you leave this blank, we will assign a counselor based on your information here as soon as possible. All of our counselors are trained as generalists in the field of counseling and can help most people. If you and your counselor agree that you need a specialist or that a different associate will be a better fit for you, they can transfer you to another associate at the center and facilitate the introduction.
Your answer
What is the best way to communicate with you about appointment times? *
If you have a current counselor or psychiatrist, please tell me their name here *
Your answer
If you have a current medical doctor, please tell us their name here *
Your answer
Please tell us what brings you to counseling at this time. *
We would like to know the main reason you are seeking counseling at this time so we can use this information to assign the best counselor associate for you. You may choose to enter information such as relationship status, challenges, psychological distress symptoms, work conflicts, or other information to facilitate our matching. The information you enter here will be seen our center's administrative staff, intake coordinator, and the clinical team.
Your answer
How urgent is your need for an appointment based on how much of a crisis or urgency you feel about the problems you listed above. *
Please note: We do not monitor this form 24/7 and it may take up to 2 business days to respond to your request. So if you or someone you are worried about is in immediate danger of being harmed or harming themselves, please call 911 or go to an Emergency Room at the hospital nearest you for an evaluation.
Not urgent, can wait for available appointments
Distress and Crisis is high, would like an appointment as soon as possible.
Notes (For Office Use Only)
Your answer
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