New Client Appointment Request Form
Please take a few minutes fill out this form to tell us a bit about yourself and how we can best serve you.  We look forward to connecting with you.

-Dance of Change Counseling Team
admin@danceofchange.com
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Today's Date: *
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First Name: *
Last Name: *
Email Address: *
Phone Number: *
Do you live in the state of Missouri? *
What is the type of service you are looking for?
 *
Is this appointment for you or someone else? *
If you choose "Someone Else" or "My Child/Dependent", please tell us their name, age and your relationship to the person:
For those seeking Marriage/Couples or Premarital Counseling (PLEASE READ)
For those seeking Marriage/Couples or Premarital Counseling:

Please read these articles on what to expect and how to get the most out of your sessinos in counseling before submitting this form. Please let us know if you have any questions. Thanks!


What can we help you with? (Please select all that apply):
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Let us know a little about you and how we can help:
 *
Any other areas of specialty you would like your therapist to possess?
Would you like to receive helpful articles and resources to improve your relationships and your mental health?
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