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
Format: (000) 000-0000.
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
Format: (000) 000-0000.
Client #2 Email
example@example.com
Are you in need of an accessible entrance for services?
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

Other
Briefly explain the reason for seeking counseling services
Are you a former KCC client?
Do you have an immediate family member who is currently a client at KCC?
Do you have a family member who is employed at KCC?
Please mark if you are interested in any of the following group therapy options:
Anything else we should know?
How did you hear about us?

Other
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