Request a Counseling Appointment at Circle Care Center

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 NameMiddle NameLast Name
Legal Name (If different from above)

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
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-personTelehealth (Virtual)No preference
Give a brief description of why you're seeking counseling?
While our counseling program offers support for a wide range of emotional, behavioral, and mental health concerns, we do not provide substance abuse or addiction treatment services. If you are seeking help for substance use, we’re happy to offer referrals to trusted professionals and programs specializing in this area.
Do you plan to use insurance for this service?

YesNo
If yes, what insurance do you have?

AnthemAetnaCignaHusky (Medicaid)HumanaKaiser PermanenteMedicareUnitedHealth GroupOther
Which provider are you requesting counseling with?

Ed Moran, LCSWCorey Hudson, LMSWNo Preference
Are you interested in receiving any of our other services? (Check all that apply)

Diagnostic Appointment (Are you feeling ill?)Sexual Health/STI Testing and TreatmentHIV TreatmentHIV Prevention (PrEP & PEP)Gender Affirming CareVaccine (Covid Booster and/or Flu Shot)MPOX VaccinePrimary Care/Annual PhysicalOther
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
Should be Empty: