Therapy Inquiry Form

Therapy Inquiry Form

Thank you for reaching out to GC Counseling. We appreciate your interest in therapy and are here to support you in finding the right therapist for your needs.
This form helps us gather important information about your preferences, availability, and therapy goals. Please take a few minutes to complete it, and we will be in touch as soon as an appointment becomes available.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Do you have health insurance that you would like to use towards therapy?*

YesNo
What health insurance carrier do you have?*
Is your insurance a medicaid or medicare plan? *GC Counseling is not in network with a any medicare or medicaid plans at this time.*

YesNoI'm not sure
Are you seeking in person or telehealth therapy?*

In PersonTelehealthNo preference

What days/times are you available for appointments?*

Please briefly share why you feel therapy would be helpful.*
Is there anything else you'd like us to know to help match you with the right therapist?
Would you like to work with a specific therapist at GC Counseling?

Glynn Couch, LCSW CASACAlly Rodriguez, LCSWAmy Dubose, LMSWDanyell Sugg, LMSWCatherine Wells, LMSWAbbie Burd, LMSW
How did you hear about us?*

Psychology TodayInstagramFacebookLinkedInwww.gc-counseling.comGoogleReferred by another providerRecommended by a friend/family memberOther
If you were referred by another provider, please share who referred you below:*
Should be Empty:

This form helps us gather important information about your preferences, availability, and therapy goals. Please take a few minutes to complete it, and we will be in touch as soon as an appointment becomes available.