New Client Inquiry & Waitlist Form

Your Next Chapter Counseling is not a crisis service.
If you are experiencing thoughts of suicide, harming others, or feel unsafe, please contact:

• Call or text 988 – Suicide & Crisis Lifeline (free & confidential)
• Mobile Crisis (WNC – Vaya Health): 1-800-849-6127
• Visit your nearest emergency room or call 911

We want to ensure you are safe and supported.
Are you currently experiencing a crisis and need immediate support?*

Yes, I need more immediate crisis support and I will reach out to the resources listed aboveNo, I’m safe at this time and ready to move forward with outpatient therapy services

For minor clients only
Parent/Guardian name (if client is a minor)
List all parent(s)/guardian(s) that have custody or custodial rights.
Is there any court or legal documentation regarding custody for this client?

Yes- All paperwork must be emailed to referrals@yournextchaptercounseling.com before your first appointment.No
In what school is this client enrolled?
Should be Empty:

For minor clients only