New Client Appointment Request Form                   
Thank you for contacting us for your counseling needs. If this is an emergency please contact 911 or visit nearest Emergency room.  Please complete this form in it's entirety for faster processing. Currently there is No Wait List same week appointments are available.  All therapy services are via tele-health at this time. Our staff member will follow up with you by email if we have any further questions prior to scheduling an appointment. Please indicate which insurance or EAP plan you will be using if you plan to use an insurance plan. Unfortunately No Medicaid , Medicare and Tricare plans are accepted at this time.  

If you are an existing client please use the Client Portal to request an appointment. 

Once we receive your form we will send you an email link to our client portal to complete registration process and appointment date confirmation. 

****Please complete all forms in the Client Portal prior to your appointment with your counselor.***

This is a HIPAA Compliant form. 
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Service Type *
Referred By *
Your Full Name *
Minor Client Name (if applicable) Please note if dual custody both parents must consent to minor child's participation in counseling. 
Client Birthday (MM/DD/YYYY) *
Phone Number *
Can we leave a detailed message on your voicemail? *
Can we send you text and email reminders for your appointment and form completion? *
Email *
United States
Clear selection
Country If Outside of United States
Address (Full Street address, City, State, Zip Code)   *
Insurance (Copay maybe required after each session) *
Self Pay Option
Please Provide Insurance Carrier Name (no Medicaid plans are accepted)
Please Provide Insurance Member ID number
If EAP, please provide name of EAP plan and your authorization code if applicable
Preferred Language *
Preferred Therapist *
Reason for counseling *
Partner Name, DOB, Phone & Email if couples counseling
3 Preferred Appointment Days and Times *
Office Only Area      (Do Not Complete)
Staff Notes
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