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 answer
Your Phone Number
Your answer
Your Email Address *
Your answer
Days and times during the week when you are available for counseling
Your answer
Name of insurance or if you will be paying out of pocket *
Does your insurance card says "Medicaid" or "Medicare" on it?
Counselor(s) you're interested in seeing *
A brief note about your primary counseling needs
Your answer
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