Counseling Request Form
By completing this form you are agreeing to a follow up phone call for further information and scheduling or referral support. If you are having a clinical or immediate emergency, please go to your local emergency room, dial 911, or 988 for support.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Will this be for yourself or a minor in your care? If a minor, please add name and age.
Marital Status
Single
Married/ Partnered
Separated/Divorced
Other
Best Time of Day for Appointments
Morning
Afternoon
After School/Evening
Flexible
Please provide a brief description of your situation.
Type of Insurance- Also specific Medicaid
If a clinician is unable to bill to your insurance would you be willing to pay self-pay?
yes
no
If you are unable to use insurance, how much would you be able to pay per session?
Do you prefer a male or female clinician?
male
female
no preference
Do you prefer virtual or in-person sessions?
virtual
in-person
no preference
How did you hear about us?
Online
Personal/Friend
Physician
Other
Submit
Should be Empty: