Request an Appointment Form ECC

Empire Counseling & Consultation Request an Appointment
How did you hear about us?*

GooglePsychology TodaySocial MediaTherapy for Black GirlsInsuranceWord of MouthTherapy for Black MenOther
Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
How would you like to be contacted for appointment scheduling?*

CallEmail
What day(s) and time(s) would you like for us to contact you?*
For our Private Policy click here Terms and Conditions click here regarding our communication policies
Do you consent for us to contact you? For our private policy and terms and conditions, please click the link above*

I consent to ECC to call/this numberThis is a safe number to be reached atI agree to check my email if that is the method I chose
What state are you located in? (or country if not US)*

CaliforniaNew YorkTexasFloridaNew JerseyGeorgiaOther
What service(s) are you interested in?*

Individual Psychotherapy (only accepting adults at this time)Couple TherapyGroup CounselingPsychological Assessment/TestingOther
If using insurance, which provider are you covered under? (Note we are only IN network with UHC for Psychological Evaluations and Testing)*

IEHPLyraUnitedHealthCareOut of NetworkPrivate PayNot Sure
Any additional information or questions you have for us
Do you agree to receive text messages from Empire Counseling & Consultation sent from 909-475-3400? Message frequency varies and may include appointment reminders, scheduling updates, and responses to general questions. Message and data rates may apply. Reply STOP at any time to opt out or HELP for assistance. For support, contact appointments@empirecounseling.net or call 909-475-3400. For details on how we handle your information, see our Privacy Policy and Terms & Conditions*

Yes, I agree to receive text messages from Empire Counseling & Consultation at 909-475-3400No, I do not want to receive text messages from Empire Counseling & Consultation.
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Empire Counseling & Consultation Request an Appointment