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)
Patient's DOB (MM/DD/YYYY)
City, State, and Zip Code
Phone Number (Please include area code)
Please answer N/A if you do not currently have an email address.
Which office location are you looking for?
Chesterfield - 6603 Irongate Square North Chesterfield, VA 23234
Powhatan - 2164 Plainview Center Powhatan, VA 23139
Midlothian - 831 Grove Road, Suite C Midlothian, VA 23114
Do you have a preference on a male or female therapist?
How did you hear about us?
Other Online Source
Primary Care Physician
Tucker Psychiatric Clinic
Poplar Springs Hospital
Reason for counseling? (Brief summary)
Play Therapy - for Children
Therapist Name (if you were directly referred to one)
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