Language
English (US)
Spanish (Latin America)
Request a Counseling Appointment at Circle Care Center
Use the form below to request a behavioral health appointment at Circle Care Center. Please note that all appointment requests will be confirmed by our staff within 1-2 business days. If you need a same-day or next-day appointment, please give us a call at 203-852-9525. **If you are experiencing a medical emergency please call 911.**
Name
*
First Name
Middle Name
Last Name
Legal Name (If different from above)
First Name
Middle Name
Last Name
Email
example@example.com
Phone Number (Cell)
*
Please enter a valid phone number.
Are you currently a patient at Circle Care Center?
*
Yes, I am a current patient.
No, I am a new patient.
No, I am a returning patient.
What type of appointment are you interested in?
In-person
Telehealth (Virtual)
No preference
Give a brief description of why you're seeking counseling?
Do you plan to use insurance for this service?
Yes
No
If yes, what insurance do you have?
Anthem
Aetna
Cigna
Husky (Medicaid)
Humana
Kaiser Permanente
Medicare
UnitedHealth Group
Other
Are you interested in receiving any of our other services? (Check all that apply)
Primary Care/Annual Physical
Diagnostic Appointment (Are you feeling ill?)
Sexual Health/STI Testing and Treatment
HIV Treatment
HIV Prevention (PrEP & PEP)
Gender Affirming Care/HRT
Vaccine (Covid Booster and/or Flu Shot)
MPOX Vaccine
Other
What days/times work best for you?
Please note that our clinical hours are Monday 9am - 7pm, Tuesday - Thursday, 9am - 5pm, Friday, 9am - 4pm.
How did you hear about us? Please select the most accurate answer
Please Select
Another Patient/Word of Mouth
Triangle Community Center (TCC)
Mid Fairfield Aids Project (MFAP)
Doctor Referral
CCC Employee
Insurance Provider
Marketing Event/Pride Event
A friend/Colleague
TV Ad
Internet Search
Saw Flyer at local LGBTQ+ establishment
Submit
Should be Empty: