New Clients

New Client Form Submission

Please fill out the following information completely and as accurately as possible. Once we receive your submission, we will be in touch with next steps.
  • Of person filling out the form
  • If different than contact name
  • Please indicate the reason for seeking counseling if "other" was selected.
  • Please indicate the type of counseling you're looking to receive.
  • Please indicate the form of payment if "other" was selected.
  • Please indicate up to two (2) choices for your requested clinician. Thank you.
  • Please indicate your preferred days and times for appointments. This does not guarantee the clinician will have these times available.