New Client Intake Form
All information is strictly confidential and follows HIPPA guidelines for secure storage of the information you provide. If you would prefer to share this information over the phone, please call us at 910-690-3884.
Client Information:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
How did you hear about us?
*
Please Select
Word of Mouth
Internet
Business Card
Other
Please Specify
Please let us know the reason you are seeking counseling. This helps us to align you with the best fit counselor for your needs.
*
Are there any legal proceedings (current or projected) involved in why you're seeking counseling? (Divorce, child custody, etc.)
Yes
No
If yes, please explain here:
Please select from the following to reflect the type of counseling you are interested in:
Professional Counseling (some insurances accepted or fee based)
Pastoral Counseling (no fee, limited scope)
Lay Counseling (no fee, 7 sessions, restrictions apply)
Professional Counseling Intern (nominal fee)
Unsure or open to suggestions
Other
If you are looking to use insurance, please let us know who your carrier is:
What day/time of the week best fits your schedule? (Ex: flexible, or Wednesdays between 3-6)
Is there anything else you would like us to know?
Thank you for your inquiry! We strive to reply within 24 hours.
Submit
Should be Empty: