Request an Appointment

Please fill out the form below to request an appointment.

Full Legal Name of Client Required

Client's Preferred Name

Client's Phone Required

Date of Birth

Additional info or requests

Email Required

I am interested in counseling for Required

Preferred Appointment Format

Either Telehealth or In Person

Telehealth

In Person

If selected "other" please list here

Location Required

By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. Message and Data Rates may apply. You can STOP messaging by sending STOP and get more help by sending HELP. Required

Yes

Insurance Required

*Please notice that communicating via email and over the Internet is not secure. Even though it is unlikely, it is possible that your email might be intercepted and read by people other than your intended recipient. Required

I have read and understand the disclaimer.

To expedite scheduling, please also provide the following information. Thank you!

Parent/Guardian Full Legal Name and Date of Birth (if applicable)

Full Address (including city, state and zip code)

Copy of front of insurance card

Copy of back of insurance card

Insurance ID/Member Number

Insurance Group Number (if applicable)

Email address for patient portal (Please note, this email must be for the client if 18+ or a legal guardian for minors.)

We offer appointment reminders. Would you like this via:

Text

Any scheduling preferences? (Please note, we have very high demand so the more flexible you are, the more likely we are to have options for you.

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Collaborative Counseling

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