Full Name
*
Please enter your first name.
Please enter your last name.
Email Address
*
Please enter a valid email address.
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have you been a Redbud Counseling Center client before?
*
Yes
No
What type of therapy are you looking for?
*
Individual Therapy
Pre-marital Counseling
Couples Counseling
What is your insurance?
*
Please provide your insurance information.
When are you available to have a therapy session? (Select all that apply)
*
Monday before noon
Tuesday before noon
Wednesday before noon
Thursday before noon
Friday before noon
Monday noon to 5pm
Tuesday noon to 5pm
Wednesday noon to 5pm
Thursday noon to 5pm
Friday noon to 5pm
I acknowledge that by submitting this form there is no guarantee that an appointment will be scheduled. I acknowledge that if I am in crisis and in need of mental health care, I will seek immediate attention at the nearest emergency room.
*
I acknowledge this statement
By checking this box, I give permission to contact me via email for the purpose of setting up a therapy appointment.
*
I acknowledge this statement
Submit Appointment Request
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