New Client Inquiry Form

Client Name*

First NameLast Name

If client is minor please add name of parent or guardian completing form:*

Client Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Type of Insurance*

What brings you to counseling at this time? Is there something specific, such as a particular event? Be as detailed as you can.*

Do you have a preference of in-person sessions or telehealth? Please contact your insurance carrier to ensure they will cover teleheath sessions.*

Do you have a specific clinician that you wish to see or are you flexible?*

Preference for sessions: Mornings, Afternoons, Evenings, Weekends (note weekends are limited hours)*

How did you hear about Kelly's Grief Center?*

Do you have a family member that is under the care of a Kelly's Grief Center Clincian?*

What is the name of the Clinician that they are seeing?*

Upon comleting this form, you will receive a welcome email from Kelly's Grief Center with a link to our secure portal. Please follow the instructions in the email to complete intake paperwork. Upon completion of the forms, you will be contacted by phone from our staff to inform you of which counselor you have been placed with and what scheduling options are currently available. Currently there is a waitlist; however we still require all forms to be completed in order to be placed on our waitlist.