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 Wellness Counseling? *

Please let us know who referred you:

Any questions or additional information we should know:

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