Contact Information Form
Welcome! We offer sliding scale, private pay, and insurance options. Please reach out if you have any questions at admin@cumberlandcenters.org!
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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: *
Email address: *
Can we use this email to send changes/updates/newsletter about Cumberland Counseling? *
Phone number: *
Date of Birth: *
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Age: *
Are you inquiring for someone else (spouse, child, parent, etc)? If so, please list their name and relation to you. *
If inquiring for someone else, please include their date of birth. 
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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? *
Required
Select the therapist you would like to work with: *
Required
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? *
Required
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) *
City and zip code *
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