First Name *

Last Name *

Email *

Phone *

Have you talked to our office manager or one of the therapists in the practice? *

Select your insurance (optional)

Insurance Card Number (optional)

Please scan and upload a photo of the FRONT and BACK of your insurance card (optional)

Date of Birth *

Select your preferred location(s) for therapy sessions *

Ramsey

Hoboken

Montclair

Virtual

What kind of counseling are you seeking? *

Select your preferred therapist *

When are you available for therapy sessions? (please include days and time frames of your availability) *

How did you hear about us? *

Please let us know who referred you:

Please share the name of the person or provider who referred you (if applicable):

Any questions or additional information we should know: *

Messaging Consent

By providing your phone number, you agree to receive text messages from Wellness Counseling. Message and data rates may apply. Message frequency varies. Reply STOP to opt out.