Intake Registration & Scheduling

Intake Registration and Scheduling

Required to create your chart and schedule your first appointment. Please call our office at (843) 894-0000 if you have any questions or concerns while completing this form.
Step 1: Complete this form.

Step 2: We will check insurance eligibility.

Step 3: We'll call you to select the appointment time!
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number. You agree to be contacted. Text message rates may apply.
Email*
example@example.com

Insurance Company*
Not using insurance? Type in "self pay"
Insurance ID#*
Upload your Insurance Card
Upload your Driver's License / State I.D.
Upload your Credit / Debit Card (If your insurance covers 100%, you won't be charged! However, this is kept on file to book the appointment in our system.)
3 digit CVV on back of card:blanks
Billing zip code:blank

Submit below!
Thanks for completing this form! We'll be in contact with you very soon!

If you don't hear from us by the next business day, please call us at (843) 894-0000
How did you hear about us?*
Anything else you would like us to know?
Signature*

Clear
l certify that the information above is accurate and complete. I agree to be contacted by Oceanic Counseling Group LLC.
Please verify that you are human*
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Intake Registration and Scheduling