Therapy Interest Form

Therapy Interest Form
New Client Interest Form

Thank you for considering ReCharge Counseling & Wellness! Please complete the form below if you are interested in pursuing services with us.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Sex
What type of therapy are you interested in?*
What prompted you to seek therapy at this time?*
Preferred availability
Preferred Time
Would you like to use insurance?
Insurance Carrier
A complimentary 15-minute phone consulation is required prior to begining services. I will contact you within 48 hours to schedule a consultation.
Should be Empty:

New Client Interest Form