Scheduling Request Form
Thanks for your interest in Calm Waters Wellness! Please complete the information below to be contacted by a member of our team. We believe that a strong therapeutic alliance is essential to your progress and want to make sure that we get it right. Your responses help us better help you! If we are not the right fit for you, we will make sure that you are referred to other trustworthy providers. 
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Client's First & Last Name *
Full name of person completing form: *
Relationship to client
Email *
Phone number *
Client's Date of Birth *
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Clients' Sex (Required for insurance verification)
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Briefly describe what has led you to seek therapy:  *
All Calm Waters Wellness therapists have unique specialties and areas of expertise. To ensure that we match you with the most appropriate clinician, please select your areas of concern:   *
Required
Are you currently seeking support for a civil or criminal court case (e.g. custody, divorce, accident, tenant/landlord, disability determination, etc.) or have you been mandated to complete counseling for any reason?  *
Do you need assistance with a short-term or long-term disability application?  *
If you answered yes to the above questions, please provide more information: 
Do you have a preferred appointment time? (Select all that apply) *
Required
Do you have a preferred appointment day? (Select all that apply) *
Required
Preferred therapy setting (Select all that apply): *
Required
In addition to traditional therapy, our providers offer Christian counseling. The goal is to not only improve mental health but also emotional, social, and spiritual health. Would you be interested in incorporating this approach into therapy?    
Do you wish to use insurance?  *
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