First Name *

Last Name *

Email *

Phone *

How did you hear about our services? *

Mental Health Insurance Company *

Insurance Card

Name of Person [Receiving Counseling] *

Which clinician do you prefer? *

Brief description of why you are looking for counseling *

What days are you available for counseling appointments? *

What times are you available for counseling appointments? *

9am - 12pm

1pm - 4pm

5pm - 8pm

Would you prefer in-person or virtual counseling appointments? *

If the individual receiving counseling is school-aged, would you be open to scheduling appointments during school hours to expedite the process? (Skip if not applicable.)

A Letter of Excuse will be provided to prevent an unexcused absence.

Messaging Consent *

By providing your phone number, you agree to receive text messages from Davis-Smith Mental Health. Message and data rates may apply. Message frequency varies. Reply STOP to opt out.

Confidentiality Notifcation *

I understand that text messages sent to my clinician will be visible to administrative staff. For confidential communication, I will use email.