New Client Inquiry
I know it can be difficult to make the decision to start therapy, and we are honored that you've taken the first step. We would love to learn more about what's going on for you now and see if we might be a good fit to work together. The new inquiry form is the fastest way to find out more information on available counseling services. Please complete the form and click the submit button. If you have not received a reply within 24 business hours, please call 844-216-1141.Thank you for reaching out!
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Number
Format: (000) 000-0000.
What is your gender?
Please Select
Male
Female
Prefer not to answer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred method of contact:
Email
Phone
No preference
If client is under 14, do both parents consent to services?
*
Yes
No
N/A
Services
*
Mental Health Counseling
Nutritional Counseling
Massage (not covered by insurance)
Insurance
*
Highmark BCBS
Anthem BSBS
Cigna/Evernorth
Aetna
United/Optum
UPMC Commercial
Medicare
UPMC for You, Highmark Wholecare, Medical Assiatance
Self Pay
Other
Reason for seeking counseling?
*
Is there a certain day or time of day that suits you best?
*
Do you have a preference for in-person or telehealth?
In-person
Telehealth
No preference
Do you have a preference for a male or female therapist?
Male
Female
No preference
Choose a Location
Hopewell PA Office (15001)
Red Bank NJ Office (07701)
How did you hear about Clarity Counseling?
Comments?
Submit
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