TRCC Application Appointment Request

First name *

Last name *

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Email *

example@example.com

May we leave a voicemail message? *

Yes No I prefer email communication

Are you currently a student? *

Yes, full-time student Yes, part-time student No, I am not a student

Are you employed? *

Yes, full-time employee Yes, part-time employee Yes, freelance/gig worker Yes, self-employed No, I am not employed

Have you been to TRCC before? If yes, when? *

Have you had therapy elsewhere? If yes, when? *

Do you have health insurance?

Yes No

Name of Insurance Company?

Does your employer provide FSA or HSA medical spending account?

Yes No