New ClientsNew Client Form SubmissionPlease fill out the following information completely and as accurately as possible. Once we receive your submission, we will be in touch with next steps. Name*Of person filling out the form First Last Name of ClientIf different than contact name First Last Phone*Email* Enter Email Confirm Email Date of Birth* Month Day Year Reason for Seeking Counseling Anxiety Depression Domestic Violence Eating Disorder Identity Development LGBTQ+ Relationship Problems Stress Substance Abuse Self-Harm/Suicidal Trauma/PTSD Other OtherPlease indicate the reason for seeking counseling if "other" was selected.Modality*Please indicate the type of counseling you're looking to receive.IndividualCouplesFamilyIntake for Group TherapyForm of Payment*Self-PayAetnaBlue Cross Blue ShieldCignaTricareUnited Health Care/United BehavioralOtherOtherPlease indicate the form of payment if "other" was selected.Requested Clinician*Please indicate up to two (2) choices for your requested clinician. Thank you. Catherine Jones Virginia Walls Sarah Richards Grace Pardieck Leslie Donovan Clarissa Lewis Tonya Thomas Preferred Days/Times of the Week for AppointmentsPlease indicate your preferred days and times for appointments. This does not guarantee the clinician will have these times available. How did you hear about us? Δ
