New Patient Form - Self-Pay
Fill this out if you would like to become a new patient at Family Guidance Centers and would like to be a self-pay patient. Our standard rate for self pay patients is $70 per visit. You will then be contacted to set up an appointment. Please allow 2-3 business days to be contacted. If you have any further questions, please call 804-743-0960 or email us at

Please note that we currently do not have psychiatric coverage on staff currently.

Patient's Full Name (Last, First) *
Your answer
Parent/Guardian Name
Your answer
Patient's DOB (MM/DD/YYYY) *
Your answer
Patient's Age *
Your answer
Street Address *
Your answer
City, State, and Zip Code *
Your answer
Phone Number (Please include area code) *
Your answer
Email Address *
Please answer N/A if you do not currently have an email address.
Your answer
Which office location are you looking for? *
Do you have a preference on a male or female therapist? *
How did you hear about us? *
Reason for counseling? (Brief summary) *
Therapist Name (if you were directly referred to one) *
Your answer
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