OTHER STATES - COUNSELING PRIVATE PAY REQUEST FORM

1

What State Do You Reside In?* This field is required.

Virginia

Texas

California

Colorado

Florida

Idaho

Illinois

Louisiana

North Carolina

Nevada

2

Are you a current client of Genesis?* This field is required.

Yes

No

3

Client Name* This field is required.

First Name

Last Name

4

Client Date of Birth* This field is required.

5

Phone Number* This field is required.

Area Code

Phone Number

6

Email* This field is required.

example@example.com

7

Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

8

Client's Sex* This field is required.

Female

Male

9

Is the Patient under 18 years of age?* This field is required.

Yes

No

10

Name of Guarantor* This field is required.

First Name

Last Name

11

Guarantor Date of Birth* This field is required.

12

Therapist Gender Preference

Male

Female

N/A

13

Reason for Requesting Services* This field is required.

14

By submitting this form, you agree to receive recurring automated promotional and personalized text and/or email messages (e.g., appointment reminders) from Genesis. Consent is not a condition of any services. You have the right to stop or cancel at any time. Msg frequency varies. Msg & data rates may apply.