Appointment Request Form

New Client Appointment Request

Zoetry Counseling Group
Please use this secure form to provide information to help us find the best counselor for you.

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Please note:

We do not accept Medicare or Medicaid

We do not accept Employee Assistance Program (EAP) benefits.

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If you are an existing client, please click here to sign in to our client portal.
Name

first namelast name
Phone
provide caregiver's phone for child / teen clientsFormat: (000) 000-0000.
e-mail
provide caregiver's email for child / teen clients
Client Date of Birth

MonthDayYear
Client Gender
Are you requesting this appointment for someone under the age of 18 years old?
Legal Custody Documentation (if applicable): Do you have a divorce decree, custody agreement, or other legal documentation that outlines your rights to make medical or mental health decisions for your child, including bringing them to therapy?
Please upload a copy of any legal custody documentation. This helps us ensure we are following all legal guidelines regarding your child’s care.

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Preferred Office / Counselor
Are you seeking EMDR therapy services?

Select the times you are typically available to meet

Please provide other pertinent information regarding your availability
Can we contact you via text message to schedule your first appointment?
Are you a military veteran or first responder?
Will you be using insurance?
We do not accept Medicare or Medicaid

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We do not accept Employee Assistance Program (EAP) benefits.
Insurance Company

Other
Insurance ID Number
Name of Primary Policyholder
If different than yourself
Date of Birth of Primary Policyholder
If different than yourself
Upload insurance card (optional)

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If you are comfortable doing so, please share something about your reason(s) for seeking therapy.
If you are requesting this appointment for someone other than yourself, please provide your name, contact information and describe your relationship to the client.
age
Assigned Counselor
How did you hear about us?

Other
Preferred Counselor
Source
SubmissionDate

MonthDayYear
SubmissionDate
SubmissionTime

Hour Minutes

AM/PM Option
Submission Date / Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

New Client Appointment Request