Appointment Request Form

Welcome to the Destined Horizons 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 will send you a registration link to begin your therapeutic journey with your assigned therapist. Rest assured, your information will remain confidential. Please avoid including sensitive medical details in this form.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Preferred Contact Method*

PhoneEmail
Best Time for Contact*

MorningAfternoonEvening
Service Interested In*

Individual TherapyCouples TherapyFamily TherapyChild and Teen TherapyLife Coaching
Reasons for seeking services*
Do you have insurance?*

YesNo
If yes, please specify your Insurance Provider
Are you interested in self-pay options?*

YesNo
I consent to being contacted by Destined Horizons regarding my consultation request.*

YesNo
Additional Comments or Questions
Should be Empty: