New Client - Initial Interest Form

Welcome to Harmony Heights Counseling and Wellness. We're glad you're here!

This secure, HIPAA-Compliant form is the best way to begin our intake process. Please complete the questions below, and our team will contact you within 24 business hours to coordinate scheduling.

 IMPORTANT: This form is for non-urgent inquiries only. If you are experiencing a medical or mental health emergency, please call 911 or go to your nearest emergency room.
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Email *
Best Phone Number to Contact You: *
Client's Name (First & Last): *
Client's Age: *
Your Full Name (if different from above): Please fill this out if you are completing this form on behalf of someone else.
Your Relationship to the Client:
For what are you're seeking therapy (check all that apply):  *
Required
What type of session format are you interested in?
Clear selection
Please specify preferred days:
What is your general availability for appointments? Check all that apply.
Do you have a preference for a therapist's gender?
Clear selection
Do you have any spiritual/religious beliefs you're hoping to have integrated into counseling? If so, please specify, and indicate if this is a requirement.
If you're planning to use insurance, who is your insurance coverage through?
If we do not have a therapist in-network with your insurance, would you be interested hearing our private pay sliding scale rates?
Clear selection
How did you hear about us?
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To ensure we match you with the right counselor please provide as much detail as possible. Please describe:

- What specific symptoms or conflicts are you facing?

- How long has this been going on, and why are you seeking help now?

- How is this impacting your daily life (work, relationships, sleep)?

 *
Is there anything else that would make you feel more comfortable or supported? Examples include your preferences regarding your therapist's style (e.g., direct vs. gentle, CBT, EMDR, etc.), identity (gender/culture), or specific scheduling nuances we missed above.
A copy of your responses will be emailed to the address you provided.
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