Full Name
*
Email
*
Phone
*
Mailing Address
*
Postal code
*
I plan to attend counseling:
*
Individually
With My Partner or Family Member
Name of Participating Partner (if applicable)
Participating partner email address
How would you like to receive services?
In-Person Only
Telehealth Only
Open to Both
Please provide a few times you are available for counseling (example: Monday's after 5pm; 7pm would be ideal)
*
What Is the best way to contact you?
Phone
Email
Text Message
Would you like to receive our best counseling and relationship advice sent to your email?
Yes
No
How did you hear about us?
Briefly describe the issue(s) you would like to work on.
Insurance Verification (If you plan to utilize your insurance)
Date of birth
Name of Insurance
Insurance ID
Front of Insurance Card (Picture)
(click to upload | .png, .jpg, .jpeg only)
Back of Insurance Card (Picture)
(click to upload | .png, .jpg, .jpeg only)
Email and SMS Text Message Risk Acknowledgement and Use Consent
*
I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to therapists, providers, and/or office staff communicating with me via email or text message
Submit