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 *
Are you (the client) over the age of 18? *
Days and times during the week when you are available for counseling:
9 AM
10 AM
11 AM
12 PM
1 PM
2 PM
3 PM
4 PM
5 PM
6 PM
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 *
A brief note about your primary counseling needs
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