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 *

(Area Code and Phone Number)

Email

Please enter a correct, FULL, valid email address

Where should the Secure Link for scheduling an appointment be sent?

Text Message
Email

(Please Select Either Text or Email)

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 planning 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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