Counseling Request Form

Counseling Request Form
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Gender*

MaleFemalePrefer not to say
Date of Birth*

MonthDayYear
Date
State of Residency *
Type of Counseling Requested*

IndividualMarriageCoupleFamilyGroup
Which counselor would you like to see?*

Dr. Adam MartinMichael Morris, LPCAubrey Hoffman, LPC-ACindy Iarussi, LMFTJaney Prevost, LPCMartha Camille Banks, LPC-AFirst Available
We will do our best to place you with your preferred counselor. We may place you with another counselor who is more suited for your needs based on availability.
Reason for requesting counseling. *
Please share anything else you would like us to know. *
After reviewing your request, our team will send you an email with a link that will allow you to login into our patient management system. Once you have completed the required intake information, we will get you placed with one of our counselors as soon as possible. If we are unable to place you within a reasonable time frame, we may offer you a referrral to help you get the care you need. If you do not see an email within 3 business days, please check your spam/junk folders for an email from The Counseling Center at Seacoast.
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