Request a Call from Oceanic Counseling
By submitting the form below, you agree to be contacted. Text message rates may apply. For immediate assistance, please call (843) 894-0000.
Full Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
By submitting the phone number above, you agree to be contacted. Messaging rates may apply.
Format: (000) 000-0000.
Email
example@example.com
Preferred Appointment Date
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Month
-
Day
Year
Date
Which Insurance Do you Have?
*
None
Medicaid (or Medicaid Products)
Medicare (or Medicare Advantage)
Tricare
Blue Cross Blue Shield / PAI
Aetna
United Healthcare
Cigna
Other
Insurance Member ID:
Insurance Card (Front)
Insurance Card (Back)
Date of Birth
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Month
-
Day
Year
Date
What type of services are you seeking?
*
Therapy / Counseling
Both therapy + medication
Are you currently taking any psychiatric medications?
Yes
No
Please list your psychiatric medications:
Preferred Service Type
*
Online / Telehealth
In-Office (Counseling / Therapy)
Office Location (If applicable)
Myrtle Beach, Carolina Forest, Murrells Inlet
Columbia / Irmo, SC
Greenville, SC
North Charleston, SC
How did you hear about us?
How did you hear about us?
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Google Search
Facebook / Instagram
Friend / Family Member
Doctor Referral
Billboard
Psychology Today
TV / News
Church / Organization
Insurance Company
Other
Tell us more:
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