Connect Counseling New Client Inquiry Form
We're eager to contact you for an opening with one of our wonderful therapists. Please provide the following information so we can match you with an appropriate fit. We look forward to serving you!

*Completion of this form does not indicate an agreement to provide therapy services or make you a client of Connect Counseling Center, LLC.  Opportunity times can vary drastically based on therapist availability and current inquiry list length.
Full Name of Client *
If client is a minor, please provide full name of legal guardian.
Please specify if this is for Individuals, Couples, or Family Therapy. If Family, please list names and ages for each participant.
Client Date of Birth *
Contact Number *
Contact Email
Contact Method Preference *
Email and text message exchanges are not necessarily HIPAA compliant.  By selecting below, I understand and assume the risks of choosing to communicate via either of these methods. *
Please select which location you prefer (choose all that apply) *
Please provide any availability restrictions. Each provider has unique availability ranging from 8:00am - 8:00pm Monday-Friday and sometimes on Saturdays.  (Example - I am available only on weekdays after 4:00pm) *
We offer both in person or virtual counseling services.  Please specify if you have a preference. *
Some providers at Connect accept the following insurances.  If you're covered under any insurance that you'd like to use, please check any that apply.  If you're interested in self-pay options if available sooner, please answer the self-pay question below as well. *
If you are not covered under the listed insurance options above or you're open to self-pay options, please select the level of provider(s) you're interested in below.  (May select multiple) *
Any additional information that will help us match you to the right fit? 
*All adults in the US are mandated reporters and any disclosure of abuse or harm to self or others will have to be reported.
How did you hear about us?  *
Would you like to opt in to receive information via email on groups occurring at Connect Counseling Center?  *
What is your billing address?  *
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