New Client Request Form

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For assisting in matching you to the best clinician to meet your needs. We will contact you regarding your request in the next 24 to 48 hours.

This is not intended to be used for emergencies- if you are experiencing a medical or psychiatric emergency, please go to the hospital or call 911.

Email *

Name *

Phone Number *

Date of Birth *

YYYY

What type of therapy are you interested in?

Individual

Family

Couples

Group

Clinical Supervision

Clear selection

Reason for seeking treatment *

Are you interested in a specific provider? *

Names & ages of other participants *

If you're seeking family therapy or couple's therapy, please provide the names and ages of the additional clients

How would you like to be seen? *

In-person

Telehealth

Either/hybrid

If telehealth, what state will you be in during sessions? *

Maryland

Pennsylvania

Washington, DC

N/A

Required

Would you like us to courtesy bill for out of network benefits? *

Yes

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This form was created inside of Pivot Point Counseling, LLC.