Therapy Appointment | Request Appointment

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New or Returning Client?

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Patient Date of Birth

Name*

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Phone Number*

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What Time is Best to Call You?

What Type of Counseling are you seeking?

Preferred Counseling Setting

Which Insurance Do You Have?*

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Front of Insurance Card (Optional)

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Back of Insurance Card (Optional)

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Reasons for Seeking Therapy*

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Office Hours
Mon – Tue: 9:00 AM – 9:00 PM | Wed - Thu: 7:00 AM – 9:00 PM
Fri: 9:00 AM – 7:00 PM | Sat: 10:00 AM – 2:00 PM

Intake Hours
Mon – Fri: 9:00 AM – 5:00 PM