Appointment Request Form
Fill out this form to get a member of our team to gather information in order to help you get set up to see one of our qualified counseling professionals. You will be contacted via email, text or a phone call by a member of our team.
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this appointment for you or your dependent
*
This appointment will be for me.
This appointment will be for my dependent.
This appointment will be for me and another participant (couples).
This appointment will be for my family.
If this appointment is for your dependent, please complete the fields below.
First Name
Last Name
This is the birthdate of my dependent.
-
Month
-
Day
Year
Date
What is the Name of your Insurance Company (or enter NONE)?
*
What is your Date of Birth?
*
-
Month
-
Day
Year
Date
What is your Member ID?
What is your Group Number?
What is the Provider Number on the back of your Insurance Card?
*
What services are you interested in? Please give names and dates of birth for others that might be attending this session with you for couple or family sessions. Please add in this space a sentence or two about what brings you to counseling to help our staff place you appropriately.
Would you like to be notified about promotional services?
Yes
No
Which option(s) work for you to be contacted?
*
Text Response
Phone Call
Email
Which service are you most interested in?
IN-person sessions in our Beaumont, TX office
IN-person sessions in our Port Neches, TX office
Virtual Counseling Sessions
Other
Are there any legal issues currently going on, or is there a custodial document on file? If so, we will need a copy of the legal documents on file. You can send them to newbeginningscounselingteam@gmail.com.
*
What time(s) of day will work for you best (we can't always accommodate everyone's first choice, but we try.
Daytime hours, morning (8a - 11a), preferred
Daytime hours, afternoon (12p - 5p), preferred
Evening hours, (5p and later), preferred
Weekend appointment
How did you hear about us?
*
Facebook
Instagram
Google Search
Website
Psychology Today
Friend/Family member
Other
Disclaimer: We utilize text messages to optimize your time
*
I agree to receive TEXT messages about appointment information from New Beginnings Counseling Team at the phone number I provided above. The SMS frequency may vary. Data rates may apply. Text HELP to 409-540-2055 for assistance. Reply STOP to opt out of receiving SMS messages. Learn more by clicking below to see our Terms and Conditions and Privacy Policy.
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