Request Consultation or Appointment

Name of person filling out this form

First NameLast Name

Name of person requesting treatment

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Ok to send texts here?

Email Address

example@example.com

How would you prefer to be contacted? Check all that apply:

What Kind of Counseling are You Requesting?

What would you like to address?

Would you like to schedule a consultation or a first appointment?

I understand that when submitting personal information on-line, there is always a risk of a third party either intentionally or unintentionally accessing my information. Ardent Grace Counseling ensures the security of your protected health information with industry-standard HIPAA-Compliant data security upon receipt by the counselor, but during transmission from me to the counselor and/or if I indicate a preference for the counselor to respond to my request via text or email, I understand that my information could be intentionally or unintentionally intercepted by a third party. By checking this box, I am indicating that I choose to accept this risk for the purposes of transmitting this form.