Request An Appointment
Thank you for considering Renewal, Growth, & Healing to support you on your journey to positive change! The quickest way to get started and request an appointment is to complete the form below. If you are requesting services for a minor, please answer the questions about the minor, not the adult who is completing the form. Please note that submitting this form does not guarantee an appointment. We look forward to speaking with you soon. *If you need assistance completing this form, please contact our Administrative Assistant at or 804-372-7463*
Sign in to Google to save your progress. Learn more
Your Full Name (First & Last Name) *If you are requesting individual psychotherapy for a minor, please provide the minor's name in this section* *
*This question is related to minor clients only--please provide the name, email address, and phone number for each parent/legal guardian
This question is related to those seeking couples therapy--please provide your partner's name, along with your partner's email address and phone number that can receive emails/calls from Renewal, Growth, & Healing
This question is related to those seeking family therapy--please provide the full names and ages of those who will be attending sessions with you
If using insurance, please provide the full name of the person who will be responsible for billing *Please type the name as it appears on the insurance card*
Renewal, Growth, & Healing emails benefits and scheduling information. We use secure email to send these messages. However, we cannot guarantee the confidentiality of content in a conventional email.
Email address to receive messages from Renewal, Growth, & Healing *
Phone number to receive calls from Renewal, Growth, & Healing *
May we leave a voice message at the above phone number? *
May we send text messages to the above phone number? *
What is the best way to reach you? *
Age of person interested in therapy *
Date of birth of person interested in therapy  *
Preferred Pronouns
Clear selection
How did you hear about Renewal, Growth, & Healing?
Primary insurance carrier: *Please indicate if you plan to self-pay* *
What is your Member ID number for your primary insurance carrier? *Typically on the front of the insurance card*
If applicable, what is your Group ID number for your primary insurance carrier? *Typically on the front of your insurance card*
What is the Provider Services phone number for your primary insurance? *Typically on the back of your insurance card*
Do you have a secondary insurance carrier?  *
Interested in:
Which therapist would you prefer to work with?  *
What service(s) are you interested in? *
Briefly describe the reason you are seeking therapy *
To ensure that we can best serve you and determine if our physical space is suitable for you, please let us know of any physical and/or mental limitations needing accommodations. 
What days and times are you usually available for sessions? *Sessions usually last 45-55 minutes* *
In order to accurately verify your insurance, it is important that we have a copy of your DMV-issued identification card and the front and back of the insurance card(s) that will be used for submitting claims. If the client is a minor, please upload the minor's  student ID along with the parents/legal guardians' DMV-issued identification card.

The identification card(s) and insurance card(s) can be sent to Please include the name and DOB of the person seeking services in the email subject.   

In the space below, please provide any additional information you would like us to know. 
Clear form
Never submit passwords through Google Forms.
This form was created inside of Renewal, Growth, & Healing. Report Abuse