Welcome
Thank you for reaching out.    Once you have submitted this form, one of our counselors will be in touch with you to better understand your goals and needs.  We strive to return all referrals within 3 business days.   
Sign in to Google to save your progress. Learn more
Email *
If you are a current client:
Please call your provider directly at the phone number listed on the website (beecounseling.com) or go to the Therapy Appointment Portal to login and message your provider.
Please select one option below: *
How were you referred to us/hear about us? *
Please tell us your first name and last initial. *
What is the best phone number to reach you?  Please note, we respond via phone only, not e-mail so please provide a number where we can reach you. *
Please indicate which provider you would like to see?  Please be aware that if that provider is unable to see a new client, another provider within our group will be recommended.   *
Please provide a brief description of what you are seeking in therapy services, including age (if request is for a child under age 18) and your main concern. *
What is the name of your insurance company?  Please do not include your policy information.  *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Bee Counseling and Consulting .

Does this form look suspicious? Report

Google Forms