Request an Appointment
Thank you for contacting Freedom Within Therapy and Wellness Center (FWC). Please complete the following and our Client Care Coordinator will reach out to you to further discuss your needs and assist in getting you scheduled.
Name *
Phone Number *
Email Address *
How did you hear about us? *
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Preferred method of communication: *
I consent to the following methods of communication and am aware that neither email or text are considered secure forms of communication. Please check any/all that apply. *
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What is the best time of day to contact you? Check all that apply.
Are you wanting to use insurance? If so, what insurance do you have?
Type of therapy:
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Is there a particular therapist you are hoping to schedule with?
What are you seeking counseling for? *
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What is your availability for therapy appointments? (Days and times)
Is there anything else you would like us to know?
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This form was created inside of Freedom Within Therapy and Wellness Center.