Name of Person Requesting Appointment *

Relationship to the Patient *

Patient First Name *

Patient Last Name *

Patient Date of birth *

Type of Therapy Requested *

Reason for Seeking Counseling

In Person or Telehealth *

In Person

Telehealth

Is there a specific therapist you are interested in seeing?

Insurance Company Name

Email *

Address *

City *

State *

Postal code *

Phone *

I acknowledge this form is an inquiry form and I understand I will fill additional Consent Forms and History Questionnaires once the first session is scheduled and when I have access to my Patient Portal.