Personal Referral for Couples Counseling Services

Personal Referral for Couples Counseling Services

Request an Appointment
Thank you for contacting Kernersville Counseling Center and submitting a self-referral form for Couple's Counseling. Once the form is completed, you will be added to our waitlist. The average wait time for a new couple to be seen is 3-4 months. Once an opening becomes available, we will contact you. If you have questions, you can contact us at 336-283-3830 or OfficeAdmin@kernersvillecounseling.com.
Insurance

WE DO NOT BILL INSURANCE FOR COUPLES COUNSELING. PAYMENT IS SELF-PAY ONLY. YOU CAN EXPECT $175 FOR THE INITIAL SESSION AND $150 FOR ALL FOLLOWING SESSIONS.
Basic Client Information
Name of Client #1*

First NameLast Name
Client #1 Date of Birth*

MonthDayYear
Date
Client #1 Gender*
Client #1 Race/Ethnicity*
Address of Client #1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client #1 Phone Number*
Client #1 Email*
example@example.com
Name of Client #2*

First NameLast Name
Client #2 Date of Birth*

MonthDayYear
Date
Client #2 Gender*
Client #2 Race/Ethnicity*
Address of Client #2 (If different from client #1)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client #2 Phone Number*
Client #2 Email*
example@example.com
Are you in need of an accessible entrance for services?*

YESNO
PLEASE NOTE THAT WE HAVE LIMITED AFTERNOON APPOINTMENT TIMES AVAILABLE.

IF NEEDED, WE WILL PROVIDE A WRITTEN EXCUSE FOR MISSING WORK.

HAVING A FLEXIBLE SCHEDULE IS LIKELY TO DECREASE YOUR WAIT TIME.

PLEASE NOTE THAT COUPLES SESSIONS ARE IN-PERSON ONLY.
Select ALL days and times that work with your schedule*

MondaysTuesdaysWednesdaysThursdaysFridaysMorningsEarly afternoonsEveningsI will take any day/time availableI must have a specific day and timeOther
Briefly explain the reason for seeking counseling services*
Are you a former KCC client?*

YesNo
Do you have an immediate family member who is currently a client at KCC?*

YesNo
Do you have a family member who is employed at KCC?*

YesNo
Please mark if you are interested in any of the following group therapy options:

Adult DBT Skills Group: a classroom-like environment where adults learn ways of handling distress, regulating emotions, engaging in mindfulness, and interacting more effectively.ANCHOR: Adult Process Group: a discussion-based environment for adults which provides mutual support, self-awareness, interpersonal skills, and attachment healing.
Anything else we should know?
How did you hear about us?

Google searchPsychology TodayHealthcare providerFriend or family memberPassed by your officeInsurance CompanyCurrent/Former Client at KCCOther
We look forward to meeting you!

Contact us if you have any questions, we are happy to help.
336-283-3830
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Personal Referral for Couples Counseling Services

Insurance

Basic Client Information

We look forward to meeting you!

336-283-3830