Dawn Counseling Connection Form
Thank you for taking the time to fill out our Connection form, we are looking forward to hearing from you!
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Is this your first time seeking Therapy?
Please give a brief description on why you would like to See Ashley at Dawn Counseling Services. (Whatever you're comfortable with)
Ashley is a Female only Holistic, Spiritual Therapist that does not prescribe medication. Are you ok with this type of treatment?
Yes!
No, Thank you!
Regardless of having Insurance or Cash paying, There is a $135 charge for the 1st visit. This fee can be refunded after insurance is verified or kept on file for future co-pay payments. Do you constent to this?
Yes
No
What Insurance do you currently have?
Will you be cash paying? Yes, or no?
Please list below the best day and times that work for you for your 1st appointment.
Are you a Texas Resident?
Yes
No
Please let me know if you have any outstanding questions or concerns, if not please put N/A.
Submit
Should be Empty:
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