New Client Inquiry Form

New Client Inquiry Form

Please complete this form and our staff will be in touch with you within two business days.
Your Name*

First NameLast Name
Your Pronouns
Your Email Address*
example@example.com
You give BaMidbar permission to add your email address to it's newsletter list.

Yes
Your Phone Number*

Area CodePhone Number
Check this box to receive text message updates from BaMidbar. Reply STOP to cancel.

Yes
Your Address*

Street Address

Street Address Line 2

CityState

Zip Code
Are you inquiring about therapy for YOURSELF or SOMEONE ELSE? If inquiring for someone else, we'll need a little more information about that them.*

MyselfSomeone else
Client Name*

First NameLast Name
Client Pronouns
Client Date of Birth*

MonthDayYear
Date
Client Email Address (if over 18)
example@example.com
You give BaMidbar permission to add the client's email address to it's newsletter list.

Yes
Client Phone Number (if over 18)

Area CodePhone Number
Check this box to receive text message updates from BaMidbar. Reply STOP to cancel.

Yes
Client Address*

Street Address

Street Address Line 2

CityState

Zip Code
May we contact the client directly?

Check this box if BaMidbar may contact the client directly.Check this box if the client is over 18 years old.
Your Date of Birth*

MonthDayYear
Date
Should be Empty: