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.
Email *
Full Name:
Phone Number:
Date of Birth:
State of Residence
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.
We are In Network providers only for BCBS. Do you wish to use Insurance to cover your sessions?
Have you ever attended therapy before?
Clear selection
Have you ever been hospitalized for mental or emotional reasons?
Clear selection
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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