New Client Inquiry Form
Please provide your basic information and details about your therapy needs and circumstances.
Full Name
*
First Name
Last Name
Who is this therapy for?
*
Myself
My Child
Couples Counseling
If therapy is for a child, please provide the child's name and age.
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Please briefly describe the main reason for seeking therapy.
If therapy is for a child, are the parents currently going through divorce or custody issues? Or is there one anticipated?
*
Yes
No
N/A
Is there any current CPS (Child Protective Services) involvement?
*
Yes
No
What type of insurance do you have?
*
Please Select
BCBS
Aetna
Cigna
SAS/First Choice
United Healthcare/UMR
No insurance/self pay
Other
Is there anything else you would like me to know?
*
Submit
Should be Empty: