New Client Counseling Registration Form
Submit your information to automatically be added to our wait-list and get connected with a counselor as soon as possible. This is for individual counseling.
Legal First Name
*
Legal Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Name
What are your pronouns?
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is it safe for us to call this phone number and leave a voicemail?
*
Yes
No
Call, but DO NOT leave a voicemail.
Email
*
example@example.com
Is it safe for us to email you information about upcoming appointments?
*
Yes
No
Yes, but do not disclose counseling information
Do you have a preference on In Person or Telehealth Appointments?
*
In-Person Only
Telehealth Only
Mix of Both
No Preference
Why are you seeking counseling?
*
Zip Code
*
Do you have insurance?
*
Yes
No
If yes, what insurance do you have? (Please put N/A if you responded No to the previous question)
*
Submit
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