Contact Information Form
Welcome! At this time we are meeting in person and online depending on the therapist that you see!
Please note we DO NOT accept insurance at this time. Please reach out if you have any questions at!
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Name: *
Is your first session already scheduled with your Cumberland therapist? (Please continue to fill out this form) *
Counseling Center Location Preference: *
Are you a referral from "Cumberland Community Cares"/Nichelle Walker? *
Email address: *
Can we use this email to send changes and updates about Cumberland Counseling? *
Phone number: *
Age: *
Are you inquiring for someone else (spouse, child, parent, etc)? If so, please list their name and relation to you. *
If you are inquiring for your child who is 18years+, please write their email below so we can connect directly with them for our first appointment (per HIPAA law). Thank you so much! *
What services are you seeking? *
Select the therapist you would like to work with: *
Please tell us why you are seeking counseling services at this time. *In order to determine if we are able to meet your needs please be detailed. *
How did you hear about Cumberland Counseling Services? *
Do you have a faith identity? *
What is your family's gross income before taxes? (This info helps us better understand the community we serve) *
Zip Code *
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