New Client Inquiry
Thank you for your interest in Looking Glass Counseling. We provide individual & group therapy for adults ages 18+. Currently, we are only seeing clients online through telehealth. We often have a waitlist for new clients, and the wait times can fluctuate. Typically, the wait time is 1-3 months for daytime appointments and 6-9 months for early mornings, evenings, weekends, and specialty appointments. To determine availability, please provide the information below. We will email you when we have an opening that suits your schedule, insurance, and preferences. If you're interested in a support group, please visit our Programs page.
Sign in to Google to save your progress. Learn more
Name: *
Email: *
Phone number: *
Age: *
Please indicate your insurance provider: *
How did you hear about us? *
Briefly, what would you like to focus on in therapy? *
If you are looking for a therapist who specializes in a specific area, please note:
Please indicate any preferences in terms of the gender of your therapist or a specific provider you would like to work with:
Our hours are 8:00 am to 9:30 pm Monday through Friday and 8:00 am to 4:00 pm on weekends. What days and times are you available for sessions? Please be specific: *
Are you interested in joining a support group? If so, what topics would you be interested in?
Would you be willing to work with a Master's level intern for an out-of-pocket fee of $40 per session? This would not go through your insurance. *
PRIVACY NOTICE
Please note that the information you provide will be kept confidential and only used for purposes of determining the right form of therapy/therapist for you. Looking Glass Counseling takes privacy seriously and does not share or sell personal information.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Pen and Press. Report Abuse