Cultivate Counseling Waitlist Form
Hello! Thank you for thinking of Cultivate Counseling for your counseling and mental health needs. We look forward to being able to support you in your journey and value the hope and courage that it's taken you to get this far.
Please take a minute to fill out the form below as this will help us get you scheduled as soon as possible. There is no commitment and if you find someone sooner you can just let us know when we call you. Currently we are expecting about 30 days for new clients to get scheduled.
If you have any further questions you can call us at 928.865.5024 or email us at office@cultivatecounselingflagstaff.com.
First and Last Name *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Why don't we start with you telling a little bit more about what your looking for? Is there any specific topic that you'd like to focus on? *
Your answer
Thank you! Next lets get some details from you.
How did you hear about us?
Your answer
Is there a specific therapist you are hoping to work with at Cultivate Counseling?
Are you willing to see another therapist if your preferred therapist is full?
Available days and times for sessions
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Notes on Availability (any details you can offer is very helpful)
Your answer
Are you willing to come in if there is a Cancellation?
What is your date of birth? *
MM
/
DD
/
YYYY
Adolescence Disclaimer
All of our therapists are mandated reporters of child abuse. What this means is if your teen discloses any abuse that hasn't previously been reported, we are required by law to make a report of this abuse. We review this mandate with all prospective clients so they know what to expect before coming in for their first appointment.
Insurance and Billing
What do you expect your billing arrangement will be? *
Required
Which in network insurance provider do you use? *
Required
Insurance ID Number
Your answer
Policy Holder Name
Your answer
Relation of the policy holder to yourself
Group Number
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Cultivate Counseling PLLC. Report Abuse - Terms of Service