Website request to be a client

Sunrise Counseling Services, LLC.

Website request for services
The following form is to request therapy services with Sunrise Counseling Services, LLC. If you are in immediate crisis situation please call 911 or the National Suicide Hotline 1-800-273-8255. You may also go to the nearest hospital emergency room for assistance. We may take up to 3 buisness days to get back to you.
Client Name

First Name Last Name
Date of Birth

Month Day Year
Date
Name of Parent/Legal Guardian filling out this form

First Name Last Name
If the client is a minor, is there a parental custody agreement?

Yes No
Email for Account
example@example.com
Phone Number
Please enter a valid phone number.
What type of therapy do you prefer?
Which state do you live in?
Therapist I'd Like to See: (Select all that may apply)

Jacqueline Carlisle Berkley, LPC-MHSP-S, (Consulting and Supervision Only) Lori Gilmore, LPC Valerie Brooks, M.S., M.M.F.T JaKay Matheny M.S., LMSW Rickey Jones, M.A. Cortlandt Mazzotta, M.A., LPC-MHSP (Online Only) Isadora Girardi, B.S. Ericka Davis, M.A., LMSW Jake Elliott, M.A. Brian Peters, M.A. Help Me Decide Need More Info (Set Up a Free 15 min Consultation with Office Manager)
If you selected "Help Me Decide," please select from the following options: (Select all that may apply)

I need the most experienced I need the most affordable I need the one I can see the quickest I prefer a male I prefer a female
Insurance/Payment Options (Select all that may apply)

Tricare BCBS Optum Untied Healthcare Aetna Cigna Centerstone Military Services Grant (12 sessions only-Must be approved through Centerstone Military Services) Use my out of network benefits (Pay for services up front & we can provide information on how to get some reimbursement from your insurance company) I'd like to pay out of pocket Tell me about your cost-effective counseling packages Health Savings Plan
How did you hear about us?
If you selected Other, how did you hear about us?
What days’ work best for you for counseling? (Select all that may apply)

Monday Tuesday Wendnesday Thursday Friday Saturday (This is only available if the therapist is available)
What times work best for you for counseling? (Select all that may apply)

Morning (9AM-11AM) Mid-Day/Lunch (12PM-2PM) Afternoon (3PM-5PM) Evenings (6PM-8PM)
Communication for Booking an Appointment *We will try to contact you by phone please let us know the best time: (Select all that may apply)

Morning (9AM - 11AM) Mid-day / Lunch (12PM - 1PM) Afternoon (2PM - 5PM) Evening (5pm-7pm) Any combination above works for me!
What types of services are you interested in? (Select all that may apply)

Addiction (Other than Drugs & Alcohol) Adolescent Anxiety Autism Spectrum Disorder Adjustment Children's Therapy Clinical Supervision Codependency Family therapy Depression Grief/Loss LGBTQI+ Adjustment/Issues Parenting Premarital Counseling Relapse Prevention Therapy Relational Issues (Individual) Relational Issues (Counseling with Significant Other) Self-Esteem Issues Stress Management Trauma/PTSD/CPTSD Teens Therapy Work/Life Balance Women's issues Other
If other, please specify:
Interest in Services (Select all that may apply)

Individual Therapy Couples Therapy Family Therapy Group Therapy
What is bringing you to counseling?
Should be Empty:

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Sunrise Counseling Services, LLC.