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Name*

First Last

Phone*

Email*

Service Requested*

Individual Counseling
Child/Adolescent Counseling
Couples Counseling
Psychiatry
Psychological Testing

Are you looking to use insurance?

Yes
No

If yes, what insurance do you have?

Treatment Setting Desired

In-Office
Telehealth (video)

Preference for Provider

Male
Female
No Preference

Preferred days and times for treatment

Please leave a short description of what has prompted you to seek treatment*

Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.

"Individual, Couples, Child Counseling"

In-Office or Therapy and Telehealth Services

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