Welcome to the DestinedHorizons consultation form! Please take a few moments to complete the sections below so we can better understand your needs. If we find that our practice is the right fit for you, we’ll send you a registration link to start your therapeutic journey with your assigned therapist. Rest assured, your information is kept confidential—please avoid including sensitive medical details here.
Name
First Name
Last Name
Date of Birth
Please select a day
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Day
Please select a month
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Month
Please select a year
2025
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Year
Phone Number
Email
example@example.com
State of Residence
Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Contact Method
Email
Phone
Best Time for Contact
Morning
Afternoon
Evening
Service Interested In
Individual Therapy
Couples Therapy
Family Therapy
Child and Teen Therapy
Life Coaching
Reason for Seeking Services:
Briefly describe your main concerns or goals
Do you have Insurance?
Yes
No
If yes, please specify your Insurance Provider
Are you interested in self - pay options?
Yes
No
I consent to being contacted by Destined Horizons regarding my consultation request.
Yes
No
Additional Comments or Questions
Thank you
Our team will review your information and contact you within 24-48 hours to move forward in the registration process.
Submit
Should be Empty: