Contact

Contact Information

First Name

Last Name

Home Address

Date of Birth

Phone Number

Counseling Services

Type of Counseling Needed

Would you like to incorporate Faith-Based Counseling?

Payment Information

Preferred Payment Method

Primary Insurance Name

Member ID

Policy Holder Address

Do you have secondary insurance?

Secondary Insurance Name

Secondary Member ID

Acknowledgment of Self-Pay Responsibility

I understand that I will be responsible for the full session fee at the time of service.

Therapy Preference

Reason for Seeking Therapy

Preferred Session Frequency

Preferred Session Times

Preferred Provider (if any)

Additional Information

How did you hear about us?

Preferred Method of Communication