First Name *

Last Name *

Is this individual the same as the primary client?

Yes, this is the primary client.
No, the primary client is someone else.

Primary Client First Name *

Primary Client Last Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

*Recommend Phone Accept Text Reminders*

Email

When is the best time to contact you?

Morning
Afternoon
Evening

(Check all that apply)

What is the best way to contact you?

Phone Call
Text Message
Email

(Check all that apply)

Who are you considering counseling for?

Myself
My Child/Dependent
My Partner and I
My Family
Other/Uncertain

(Check all that apply)

What type of payment option(s) are you considering for services?

Primary Insurance
Secondary Insurance
Employee Assistance Benefits (EAP)
Self Pay
Other/Uncertain

(Check all that apply)

Briefly describe the primary reason you are seeking counseling currently? *

Additional Comments/Questions:

Please retype the characters in the box below: *

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