Appointment Request Form
To schedule an individual counseling session, couples counseling session, or family therapy appointment, or to register for one of our groups, fill out the form below or give us a call.
Your Name *
Your Phone Number
Your Email Address *
Days and times during the week when you are available for counseling
Name of insurance or if you will be paying out of pocket *
Does your insurance card says "Medicaid" or "Medicare" on it? *
Are you open to working with us on our Self-Pay Sliding Scale Fee? *
Rates would range from $45 - $80 per session ($50-$95 for couples/family), depending on your income.
Counselor(s) you're interested in seeing *
Required
A brief note about your primary counseling needs
Submit
Never submit passwords through Google Forms.
This form was created inside of Oasis Counseling Center. Report Abuse