New Client Registration Form - Urban Healing Counseling
Thank you for your interest in working with Urban Healing Counseling PLLC! We appreciate your interest in working with our office. If you are experiencing a mental health crisis or if you are currently experiencing suicidal ideations, please do not complete this form. Instead, call 911 or go to the nearest emergency room.
Date of Birth:
State of Residence
What is the best time of day for appointments? You may choose multiple:
Mornings (7 am - 11 am)
Afternoons (12 pm - 4 pm)
Evenings (5 pm - 8 pm)
What are the best days of the week for you? You may choose multiple:
Which therapist(s) are you interested in? If you choose multiple, our administrative team will explore your schedule and needs further to help you find the best fit.
Help me choose
We are In Network providers only for BCBS. Do you wish to use Insurance to cover your sessions?
Yes - I want to use BCBS Insurance
No - Please share your Private Pay Rates
Have you ever attended therapy before?
Have you ever been hospitalized for mental or emotional reasons?
What issues are you struggling with? Choose all that apply.
Why are you seeking therapy? (Please elaborate in 1-3 sentences)
How did you hear about us?
Current or past client
Online Google Search
Therapy for Black Girls
Doctor, psychiatrist, other mental health professional
Friend or family member
Facebook group mention
Never submit passwords through Google Forms.
This form was created inside of Urban Healing Counseling PLLC.