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.
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Email *
Full Name: *
Name of Guardian
Phone Number:
Date of Birth:
State of Residence *
I am a
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What is the best time of day for appointments? You may choose multiple: *
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. *
Do you wish to use Insurance to cover your sessions? *
Have you ever attended therapy before?
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Have you ever been hospitalized for mental or emotional reasons? *
Is this court ordered therapy?
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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? *
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