New Client Interest Form
First Name
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Last Name
*
Date of Birth
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Phone
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Email
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Are you seeking counseling for yourself or someone else?
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Myself
My spouse/partner
My minor child
My adult child
My friend/family member
I'm a professional making a referral
What type of counseling are you seeking?
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Individual
Marriage/Couples
Family
Would you prefer in office or online appointments?
I want in office sessions only.
I want online sessions only.
I want the flexibility to do in office and online sessions.
Which state do you live in?
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Louisiana
Texas
Tennessee
Which counselor would you like to work with?
No Preference
Bridget Worsham (Louisiana)
Brittany Washington (Tennessee)
Jacquelyn Kirby (Louisiana)
Jasmine Brown (Texas)
Latoya Randall (Louisiana)
Lois Zeno (Texas)
Margie Daniels (Louisiana)
Mary Dyas (Louisiana)
Michelle McKellar (Louisiana)
Renee Spell (Louisiana)
Ruth Caldwelll (Louisiana)
Shaquwanda Chew (Louisiana)
Sofia Small (Louisiana)
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Are there specific days or times that work better for you?
How will you be paying?
Insurance
Self-pay
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Who is your insurance carrier?
Aetna
Aetna Meritain
Aetna Health Plus
BCBS
Christus Health Plan
Cigna/Evernorth
Medicaid
Medicare
Medicare Advantage Plan
Optum
Tricare
United Healthcare (UHC)
United Medical Resources (UMR)
Vantage
Other
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Upload a picture of the front and back of your insurance card here and I will verify your coverage to let you know how much session cost.
Any questions or additional information we should know:
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