New Client Inquiry & Waitlist Form

Client's Legal Name (required for insurance purposes)*

First NameLast Name
Client's Preferred Name (if different than above)

First NameLast Name
Client's Date of Birth*

MonthDayYear
Date
Email*
Phone Number*
Please indicate which method(s) of communication you consent to receiving.*

Phone CallVoice MessageEmailText MessageAll of the above
Please indicate which method of communication you PREFER to receive.*

EmailText messagePhone callNo preference
What insurance will be used to pay for sessions?*
Please note that the type of insurance that each therapist accepts varies, so your therapist options may be limited by your insurance.
Please briefly describe why you are seeking counseling at this time.*
This information will remain confidential and only be used to determine which therapist will be the best fit.
Which therapist do you prefer to work with?*

UNSURE; I would like the referrals coordinator to match me with someone.Angie KingAshley HayesAudrey TannerBaylor BrownBryan GilletteBryan MichalowskiCatherine MorrisonChelsea SinkovichElide Gonzales PerezEmmi LohrentzHannah KupsovHope HinsonHunter WaldropJoey BaneKristin GoodmanKyla RoheMaryAnne Tatum-WattsRenee PicconeSamantha BlytheOther
Which location do you prefer?*

Asheville Office: 19 Zillicoa Street, Asheville, NC 28801Hendersonville Office: 322 8th Avenue East, Hendersonville, NC 28792Virtual/TelehealthNo preference
What days & times are you available to meet with your therapist for sessions?*
Is there anything else you think the referral coordinator or therapist should know at this time?
Please upload a photo of the front and back of your insurance card.

Optional, but we do need any insurance info you may have before we can schedule you an appointment.
Cancelof
This client is a minor (under the age of 18 years old)*

YesNo

For minor clients only